Failure to Protect Resident from Abuse Due to Inadequate Supervision and Documentation
Penalty
Summary
The facility failed to protect a resident from physical and verbal abuse by another resident with a known history of aggression and severe cognitive impairment. One resident, who had vascular dementia, impulse disorder, and was severely cognitively impaired, frequently propelled his wheelchair throughout the facility, entered other residents' rooms, and exhibited both verbal and physical aggression toward staff and other residents. On the date of the incident, this resident entered another resident's room, was told to leave, and responded by punching the resident in the arm and attempting to kick her. The aggressor was removed immediately, and the victim was assessed and found to have swelling but no visible injury. Multiple interviews and record reviews revealed that the aggressive resident had a documented history of similar behaviors, including entering other residents' rooms, pushing residents, and being physically and verbally aggressive during care and in the dining room. Staff and leadership acknowledged that the resident required close supervision and redirection, but documentation of these behaviors and interventions was inconsistent or lacking. The care plans for the aggressive resident were not updated to reflect the need for close supervision, did not include non-pharmacological interventions, and failed to document triggers or strategies to prevent recurrence of aggressive behavior. Staff interviews indicated a lack of awareness or familiarity with care plan interventions, and there was no clear communication or documentation of how care plan changes were shared with staff. Additionally, the facility's documentation practices were deficient. Treatment Administration Records (TARs) and care plans did not consistently record the resident's aggressive behaviors, non-pharmacological interventions, or the need for close supervision and redirection. There was also a lack of documentation regarding the identification and monitoring of behavioral triggers. Staff training records on dementia and behavior management were incomplete due to a recent change of ownership, and some staff were unaware of the behavioral interventions required for the resident. These failures contributed to the incident of resident-to-resident abuse and placed other residents at risk.