Failure to Implement Interventions Following Behavioral Complaints Led to Resident Altercation
Penalty
Summary
The facility failed to protect two residents from abuse by not implementing interventions in response to repeated behavioral concerns and a resident complaint. One resident, with a history of mood disorder, depression, anxiety, and chronic pain, exhibited verbally threatening behaviors almost daily and demonstrated depressive moods. Another resident, diagnosed with schizoaffective disorder, PTSD, anxiety disorder, and bipolar disorder, also experienced depressive moods. Despite ongoing complaints from residents and staff about one resident's behavior of placing meal trays on another table, no interventions or care strategies were documented or implemented to address the issue. An altercation occurred during dinner when one resident struck another after being verbally provoked, resulting in both sustaining injuries that required first aid and hospital evaluation. Multiple interviews confirmed that staff were aware of the ongoing behavioral issue and resident complaints but failed to act or document any interventions. The facility's abuse prevention policy requires timely response to consumer concerns, but records showed no evidence of such actions prior to the incident.