Failure to Protect Resident from Physical Abuse and Lack of Incident Reporting
Penalty
Summary
The facility failed to protect a resident from physical abuse when one resident reported being struck by another resident who entered his room. The resident who committed the act had a documented history of severe cognitive impairment, fluctuating behavior, agitation, aggression, and previous incidents of intrusive and aggressive actions toward others and staff. Despite these behavioral concerns and a recent wrist fracture of unknown origin, there was no documentation in the clinical records regarding the altercation, no updated care plans, and no evidence of protective interventions implemented after the incident. Multiple staff interviews revealed that two certified nursing assistants (CNAs) witnessed the aggressive resident attempting to strike the other resident, who was in bed at the time. The CNAs responded to calls for help and intervened to prevent further aggression. The incident was reported to the charge nurse, but not to the administrator or other required parties. The charge nurse and registered nurse supervisor both denied knowledge of the altercation, and there was no documentation or reporting of the event in the clinical records for either resident. The social services representative and director of nursing also confirmed they were unaware of the incident and emphasized that such events should be reported and investigated promptly. The facility's own policy prohibits any form of resident abuse and requires reporting and intervention. However, the lack of documentation, failure to update care plans, and absence of protective measures following the altercation demonstrate a breakdown in communication and adherence to policy. The incident left the affected resident feeling violated and unsafe, and the facility did not take the necessary steps to address or prevent further abuse.