Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from resident-to-resident abuse, specifically involving a resident with severe cognitive impairment and problematic behaviors, including physical and verbal aggression. The resident, who had diagnoses such as Parkinson's disease, epilepsy, and intellectual disabilities, exhibited frequent episodes of yelling, hitting, and throwing objects at both staff and other residents. Despite having a care plan with multiple interventions to address these behaviors, documentation shows that the resident continued to be aggressive and unable to be redirected, with daily reports of physical and verbal aggression toward others. Another resident, who had moderate cognitive impairment and a history of anxiety and depressive symptoms, expressed fear for his safety due to his roommate's violent behavior. Progress notes and staff interviews confirm that the aggressive resident yelled at, cursed, and threatened his roommate, causing the latter to feel unsafe in his own room. The roommate reported being scared and stated that if the aggressive resident could hit staff, he could also harm him. Although the aggressive resident did not physically harm his roommate, the ongoing verbal aggression and threats created a hostile and unsafe environment. Staff interviews revealed that the incidents were not consistently reported to facility leadership, and not all residents at risk were interviewed regarding potential abuse. The Director of Nursing was unaware of the incident until later, and the Social Worker Director did not document all relevant interviews, believing them to be unimportant. The facility's policy required protection from abuse, but the actions taken were insufficient to prevent resident-to-resident abuse, resulting in a deficiency.