Failure to Prevent Resident-to-Resident Abuse Due to Inadequate Supervision and Intervention
Penalty
Summary
The facility failed to protect multiple residents from abuse, specifically physical aggression perpetrated by another resident with a history of severe cognitive impairment and behavioral disturbances. Several incidents occurred in which this resident physically assaulted peers, resulting in injuries and hospital evaluation for at least one victim. The aggressive resident had a documented history of Alzheimer's disease, depression, bipolar disorder, anxiety, and mood disorder, with a severely impaired cognition score. Despite being placed on 1:1 supervision due to repeated aggressive episodes, the resident continued to initiate unprovoked physical aggression toward others, including hitting, pushing, and punching fellow residents. The affected residents, all with varying degrees of cognitive impairment and complex medical histories, were subjected to physical aggression on multiple occasions. One resident was hit in the chest and fell, requiring hospital evaluation; another was punched in the face; a third was pushed to the ground; and a fourth was struck on the arm. Care plans for these residents documented the incidents and included interventions such as removal from the aggressor and monitoring for injuries. However, these measures did not prevent further occurrences of abuse, and staff interviews revealed ongoing concerns about the safety of both residents and staff due to the aggressor's unpredictable and escalating behavior. Staff and leadership interviews indicated that attempts to secure psychiatric intervention or alternative placement for the aggressive resident were unsuccessful, as hospitals and other facilities declined admission, and legal barriers prevented emergency detention. Staff reported feeling unsafe and unable to manage the resident's physical aggression, citing the resident's size and strength. The facility's abuse prevention policy emphasized the importance of resident safety, but the repeated incidents and lack of effective intervention resulted in the identification of Immediate Jeopardy by surveyors.
Removal Plan
- Ensure Resident #11 is placed on continuous 2:1 supervision at arm's length.
- Implement physical separation at arm's length between Resident #11 and all other residents at all times, accomplished by in-services to all staff.
- Place Resident #11 in a controlled, low-stimulation environment.
- Search the memory care common area and Resident #11's room to ensure objects that could be used to cause harm are removed from the resident's environment.
- Implement a two-staff approach for all care interactions involving Resident #11.
- Request and complete a psychiatric evaluation for Resident #11, with medication changes and additional diagnosis as a result.
- Review and adjust Resident #11's medication regimen and PRN parameters as clinically indicated.
- Review Resident #11's clinical status to assess for potential medical contributors to aggressive behavior, including pain assessment, vital signs, infection screening, bowel and bladder status, and medication profile.
- Revise the process for managing residents with aggressive behaviors, including early identification of triggers, defined escalation thresholds, and clear staff response expectations.
- Revise Resident #11's behavioral care plan by the interdisciplinary team to include identified triggers, early warning signs, de-escalation techniques, and clear direction for escalation.
- Educate DON and ADON regarding dementia-related aggressive behaviors, resident to resident abuse prevention, and de-escalation strategies, validated by quiz.
- Conduct education for staff on all shifts regarding dementia-related aggressive behaviors, resident-to-resident abuse prevention, and de-escalation strategies; staff, including PRN and Agency, will be unable to work until education is completed and validated by quizzes with a minimum score of 100%.
- Reinforce the Abuse Prevention Policy with specific focus on resident-to-resident aggression.
- Reinforce pathways of resources for staff for psychiatric consultation and alternative placement consideration and place in a binder at the nurses' station for staff accessibility.
- Conduct a house-wide assessment to identify residents at risk for harm, and implement protective interventions for all residents in the memory care unit.
- Provide immediate oversight of supervision levels and resident safety related to aggressive behaviors.
- Provide real time supervision during each shift to ensure protective interventions and separation measures remain in place; any escalation in aggressive behaviors results in immediate re-assessment and modification of interventions.
- Maintain active presence in oversight to ensure continued resident safety and adherence to interventions implemented to remove the jeopardy.
- Monitor resident-to-resident aggression through the QAPI program with trend analysis; review findings by the QAPI Committee and implement corrective actions as needed.
- Conduct ongoing audits to ensure compliance with supervision, care planning, and staff response protocols.