Failure to Prevent Resident-to-Resident Abuse Resulting in Injuries
Penalty
Summary
The facility failed to ensure that residents were protected from abuse, resulting in multiple resident-to-resident altercations involving five residents. Several incidents occurred where residents with severe cognitive impairments and behavioral issues engaged in physical altercations, leading to injuries such as facial lacerations, abrasions, and scratches. For example, one resident with Alzheimer's disease and severe cognitive impairment wandered into another resident's room, resulting in a physical confrontation where both parties sustained injuries. Another incident involved two residents in a hallway altercation, where one attempted to grab the other, leading to a physical response that caused further injury. The residents involved had significant medical and behavioral histories, including diagnoses of Alzheimer's disease, dementia, mood disorders, and psychosis. Many required extensive assistance with activities of daily living and exhibited behaviors such as wandering, aggression, and rejection of care. Despite these known risks, the facility did not consistently prevent residents from entering others' rooms or from coming into close contact in common areas, which contributed to the altercations. Staff interviews confirmed that some residents were known to wander and had a history of confusion regarding room locations, yet interventions to prevent these interactions were not always effective or timely. Documentation and interviews revealed that staff were aware of the behavioral risks and had care plans in place, but these interventions did not prevent the incidents from occurring. In some cases, staff were not able to intervene before physical contact was made, and there was inconsistency in reporting incidents to local authorities. The facility's approach to determining whether an incident constituted abuse varied, with some staff not initially recognizing resident-to-resident altercations as abuse. This lack of consistent prevention and recognition of abuse led to multiple residents sustaining injuries as a result of altercations.