Failure to Prevent Resident-to-Resident Abuse and Neglect
Penalty
Summary
The facility failed to protect multiple residents from abuse, neglect, and exploitation, as evidenced by several resident-to-resident altercations resulting in physical injuries. Two residents with a history of verbal and physical aggression toward each other engaged in altercations on more than one occasion, leading to minor injuries such as skin tears and scratches. Documentation shows that both residents had care plans identifying their potential for aggression, but despite interventions such as environmental modifications and medication reviews, altercations still occurred in common areas like the hallway and dining room. Staff interviews confirmed that these incidents were witnessed, and that the residents involved would taunt and provoke each other, with staff sometimes intervening only after the altercations had escalated. Another incident involved a resident with severe cognitive impairment who wandered into another resident's room and was struck by an electric wheelchair, resulting in a skin tear. The resident who operated the wheelchair had intact cognition but significant physical limitations and required supervision when using the motorized device. Despite care plans noting the need for supervision and the potential for physical aggression, the incident occurred when the resident with cognitive impairment became confused and entered the wrong room. Staff interviews indicated that the cognitively impaired resident frequently wandered and became confused, and that she had been involved in other incidents that required investigation. The report details that the facility's policies require protections against abuse, neglect, and exploitation, including screening prospective residents and implementing interventions for those at risk. However, the documented events show that these measures were insufficient to prevent resident-to-resident altercations and injuries. Staff accounts reveal that attempts to separate residents or modify their environment did not always prevent further incidents, and that some staff were not immediately available to intervene during altercations.