Failure to Prevent Resident-to-Resident Abuse Due to Ongoing Aggressive Behaviors
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by two separate incidents involving aggressive behavior by one resident towards others. In the first incident, a male resident with a history of physically and verbally aggressive behaviors, moderate cognitive impairment, and multiple psychiatric diagnoses, threw coffee at another male resident, resulting in redness to the face and chest. The nursing assessment completed the same day found no injury or changes in the skin assessment from baseline. The aggressive resident had a documented pattern of agitation and aggression, with care plan interventions in place, but continued to exhibit behaviors such as hitting, throwing objects, and verbal outbursts. In the second incident, the same aggressive resident struck another male resident on the left side of the face/jaw with a closed fist during an activity. The resident who was struck had a history of traumatic subdural hemorrhage, dementia, and unsteadiness on his feet, and was noted to be rarely or never understood. The nurse assessed no injuries following the incident. The aggressive resident had a care plan that included interventions for behavioral symptoms, but he consistently refused his prescribed psychotropic medications and psychiatric services, and his aggressive behaviors persisted despite staff attempts at redirection, monitoring, and environmental modifications. Staff interviews and record reviews revealed that the aggressive resident had a long-standing pattern of combative and disruptive behaviors, including multiple episodes of aggression towards both staff and other residents. Despite frequent monitoring, care plan updates, and attempts to accommodate his preferences and needs, the facility was unable to prevent further incidents of resident-to-resident abuse. The aggressive resident's refusal of medication and psychiatric intervention, combined with his independence and quick actions, contributed to the facility's inability to ensure the safety and protection of other residents from abuse.