Failure to Protect Resident from Ongoing Abuse and Inadequate Behavioral Interventions
Penalty
Summary
The facility failed to comprehensively assess, develop, or implement effective interventions to reduce the risk of ongoing physical and mental abuse between two residents. One resident with moderate cognitive impairment, schizoaffective disorder, and a history of behavioral disturbances repeatedly harassed and physically grabbed another resident, who also had moderate cognitive impairment, dementia, anxiety disorder, and a history of delusional thinking. Despite over 20 documented behavioral incidents involving the aggressor, the facility's records lacked detailed descriptions of the behaviors, the specific interventions attempted, and their effectiveness. The primary intervention used was redirection, which was consistently noted as ineffective, and there was no evidence that alternative strategies were considered or implemented. Direct care staff and medication aides reported that the aggressor persistently sought out and targeted the other resident, engaging in behaviors such as hair pulling, grabbing, and entering her room, which caused significant emotional distress. Staff interviews revealed that these incidents had been ongoing for several months, and that management was aware of the situation. However, the care plans for both residents did not include specific interventions or strategies to address the repeated interactions or to protect the victim from further harm. Documentation also showed that the aggressor's care plan lacked a behavioral focus or interventions related to her actions toward other residents. The victim experienced increasing anxiety and distress as a result of these interactions, leading to multiple calls to 911, involvement of law enforcement, and eventual hospitalization for psychiatric care. Despite these outcomes and repeated documentation of the aggressor's behaviors, the facility did not conduct a comprehensive assessment or implement effective interventions to ensure the victim's safety. The facility's abuse prevention policy required identification and investigation of patterns or trends that may constitute abuse, but there was no evidence that the ongoing incidents were reported or investigated as potential abuse, nor that the required immediate interventions were put in place.