Failure to Prevent and Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident verbal and physical abuse involving one resident with a history of post-traumatic stress disorder, anxiety, schizoaffective disorder, and other medical conditions. The incident involved another resident with schizoaffective and major depressive disorders, who became verbally and physically aggressive during the night, pulling back privacy curtains, playing loud music, turning on bright lights, and ultimately physically attacking her roommate. The aggressor hit the roommate multiple times, threw personal items at her, and attempted to take her walking cane to use as a weapon. The victim reported experiencing significant physical pain, mental anguish, and fear following the attack, stating she was sore for a week and afraid to sleep. Staff responses to the incident were inconsistent and inadequate. One CNA witnessed the argument but did not report it, believing it was not abuse. Another CNA and an LPN intervened during the physical altercation, separating the residents and removing the victim from the room. However, there was confusion and inaccuracy in the documentation of witness statements, with one CNA denying authorship of a written statement attributed to her and stating she was never asked for her account of the incident. The facility's Director of Nursing and Administrator were notified of the incident but did not fully investigate or ascertain the extent of the physical abuse until several days later. Neither asked the victim if she had been physically struck or injured during their initial follow-up. The facility's abuse policy requires immediate reporting and thorough investigation of suspected abuse, but these procedures were not followed. The incident was not promptly or accurately reported to the appropriate authorities, and the severity of the abuse was not recognized or documented in a timely manner. The lack of immediate and thorough investigation, as well as the failure to recognize and report the abuse, resulted in the resident experiencing ongoing pain and emotional distress.