Failure to Address Behavioral Incident Leads to Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by not addressing a significant behavioral incident and not implementing appropriate interventions. One resident, with diagnoses including dementia, schizoaffective disorder, depression, and anxiety, exhibited a change in behavior by screaming at another resident. This behavioral change was not documented, monitored, or communicated to the physician as required by facility policy, nor was it incorporated into the resident's care plan. Staff separated the residents during the incident but did not report the event to a licensed nurse or take further action. Following the unaddressed behavioral incident, another resident subsequently hit the first resident in the face, resulting in a scratch under the eye and redness on the nose. The injured resident was severely cognitively impaired and dependent on staff for most activities of daily living. The resident who struck the other had moderate cognitive impairment and physical limitations. Interviews revealed that staff were aware of the first resident's tendency to invade others' personal space but did not report or document these behaviors, assuming it was common knowledge. The Director of Nursing acknowledged that the initial behavioral incident should have been treated as a change of condition, requiring immediate communication with the physician and care plan updates. Facility policies reviewed during the investigation emphasized the need to identify, document, and manage problematic behaviors and to intervene in situations likely to lead to abuse. The lack of documentation, monitoring, and intervention after the initial incident directly contributed to the subsequent physical altercation and injury.