Failure to Prevent and Document Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from resident-to-resident abuse, resulting in multiple incidents involving physical and verbal aggression. One resident with a history of mental illness, including depression, anxiety, PTSD, and bipolar disorder, exhibited daily physical and verbal aggressive behaviors toward both staff and peers. Despite having care plans and interventions in place, such as behavior analysis, de-escalation techniques, and staff providing care in pairs, the resident continued to engage in aggressive acts, including hitting, yelling, and using inappropriate language toward other residents. Documentation revealed repeated altercations where this resident struck other residents in common areas, hallways, and during meal times, sometimes without provocation and sometimes following verbal exchanges. The facility's records showed that staff intervened by separating residents and redirecting the aggressive resident to her room, but these interventions did not prevent further incidents. There were also lapses in documentation, such as missing behavior charting and incident investigation summaries for some altercations. The care plans and individual program plans for the aggressive resident were not consistently updated following incidents, and there was a lack of timely evaluation and adjustment of interventions after repeated episodes of aggression. Staff interviews confirmed awareness of the resident's behaviors and the occurrence of multiple incidents involving physical aggression toward other residents and staff. Other residents involved in these incidents had diagnoses including anxiety, schizophrenia, and bipolar disorder, and some reported emotional distress following altercations. While some residents denied being afraid, they expressed concern about future incidents. The facility's policies required protection from abuse and outlined procedures for reporting and managing resident-to-resident altercations, but the repeated nature of the incidents and incomplete documentation indicated a failure to fully implement these protections and prevent abuse.