Failure to Protect Residents from Physical Abuse by Peers
Penalty
Summary
Facility staff failed to protect multiple residents from physical abuse by other residents, resulting in several incidents of harm and injury. In several documented cases, residents were physically assaulted by peers, including being punched in the face, head, or chest, and in some cases, these assaults resulted in hospital transfers, visible injuries such as bruising, lacerations, abrasions, and the need for medical treatment. The incidents involved residents with known behavioral issues or histories of aggression, some of whom had orders for 1:1 supervision or required supervision during specific activities such as smoking. Despite these known risks, staff did not consistently provide the required supervision or intervene in time to prevent altercations. Specific events included one resident being repeatedly assaulted by a roommate, another being attacked in a smoking area where supervision was required but not provided, and others being struck in common areas or hallways. In several cases, staff documentation was incomplete or failed to describe the altercations, and there were lapses in following care plans or behavioral interventions. Witness statements and staff interviews confirmed that staff were not always present or able to intervene promptly, and that some residents were fearful of aggressive peers due to repeated incidents. The facility's own policies defined physical abuse as intentional harm by another person, and staff interviews confirmed their understanding of the responsibility to protect residents from abuse by anyone, including other residents. However, the documented events show that staff did not consistently implement or maintain necessary supervision, failed to reassess and update care plans in response to behavioral changes, and did not always document or communicate incidents effectively. These failures resulted in immediate jeopardy to resident safety and placed all residents at risk of abuse.
Removal Plan
- Resident #32, #7, #26 are under 1:1 supervision with staff in close proximity to deescalate or intervene with any possible altercations.
- Resident #40 and #26 will not be allowed to smoke unsupervised.
- A dedicated staff member has been assigned to monitor residents #40 and #26 during smoking breaks.
- A dedicated staff member has been established in the designated smoking area within a secure part of the facility grounds.
- Resident #37, #41, and #39 will have trauma screens performed on all residents that were abused by other residents.
- Resident #12 and #43 no longer reside in the facility.
- All staff will be educated on the abuse policy.
- The DON or designee will educate on abuse and 1:1, ensuring staff doing 1:1 are in close proximity to intervene and provide privacy during bodily functions.
- The DON or designee will conduct an audit of residents currently on 1:1 to ensure the person assigned is monitoring the patient.
- Nursing staff on all shifts will document any unusual, increased, or change in behaviors in the medical records.
- Clinical review will determine residents at risk for aggressive behaviors and appropriate interventions will be put in place.
- All residents that require supervised smoking will be evaluated using the Smoking Safety Screen Assessment upon admission and as needed.
- Current residents that smoke will be reassessed using the Smoking Safety Screen Assessment to determine if supervision is required.
- The facility will schedule a staff member to be in the courtyard while smoking occurs.
- The Interdisciplinary Team (IDT) will be educated by the Regional Director of Clinical Services on the policy and procedures to identify abuse.
- IDT will be educated on what a 1:1 entails, including maintaining arm's length inside and outside of the room.
- Anyone providing 1:1 care will be scheduled by staffing with their relief person for break noted on the schedule.
- Resident on 1:1 will be documented on daily by assigned staff, collected by charge nurse.
- Staff will be educated that they may not leave the resident until they have a relief person and must remain in close proximity to intervene.
- The Regional Director of Clinical Services will educate the IDT team on the need for supervision for residents identified as requiring supervision while smoking.
- The DON or designee will create a schedule for supervision of residents that smoke and ensure they are in the smoking courtyard while residents requiring supervision are present.
- This education will be provided to all staff, and no employee will be allowed to work until they are educated, including agency staff.
- A review of resident #32, #7, #26 care plan will be conducted to assess the effectiveness of the interventions and make adjustments.
- The DON or designee will audit residents with 1:1 supervision to ensure staff is remaining in close proximity to intervene.
- Facility will monitor all residents who have been identified as supervised smokers.
- All supervised smokers will smoke in the designated smoking area within a secure part of the facility grounds.
- If supervision is deemed necessary, the resident will be supervised by a designated staff.
- The DON or designee will audit residents who are supervised smokers to ensure they are supervised while smoking.