Failure to Protect Cognitively Impaired Resident From Physical Abuse by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. One resident with dementia, major depressive disorder, and anxiety disorder had a documented history of behavioral problems, including sexually inappropriate comments to female staff, persistent yelling out, and verbal and physical aggression toward staff during care. His care plan, initiated in early October, identified these behaviors and included interventions such as administering medications as ordered, anticipating and meeting needs, intervening to protect the rights and safety of others, using calm approaches, diverting attention, and removing him from situations as needed. Behavior notes from late December documented that this resident was up and down all night, was restless, was looking for a family member, and expressed dislike and suspicion toward another male resident, stating he did not like the other resident looking at him and questioning why he was there. Staff attempted redirection several times, which was ineffective, and administered anti-anxiety medication for increased restlessness. The alleged victim was another resident on the same memory care unit, also with dementia and anxiety disorder, and with a BIMS score indicating severely impaired cognition. This resident did not exhibit behavioral symptoms or wandering. Both residents had been on the same unit since mid-December. On a day after lunch, the cognitively impaired victim was sitting at a dining room table, asleep and wearing a cowboy hat, with his back facing the other resident. The resident with behavioral issues was observed by staff coming out of his room looking very angry and moving quickly toward the sleeping resident. He then hit the back of the other resident’s head, knocking the cowboy hat off. Staff documented that the aggressive resident repeatedly stated that the other resident had just gotten out of prison and had denied him a job. A CNA witness described seeing the resident smack the back of the sleeping resident’s head, and considered this to be physical abuse. The facility’s own investigation and leadership interviews confirmed that the incident constituted abuse. The 5-day investigation report documented that the CNA saw the aggressive resident smack the cowboy hat off the other resident and that both residents were unable to recall the event. The DON stated that the aggressive resident went straight to the other resident and smacked his hat off, and that this action was not allowed and was considered physical abuse, even if the DON believed the hat rim was struck. The administrator also stated that the aggressive resident hit the back of the other resident’s head and considered it abuse. The facility’s abuse policy defined abuse broadly and required identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, and witnesses. Despite prior documentation of the aggressive resident’s behavioral issues and recent agitation directed toward another male resident, the incident occurred, demonstrating that the facility did not effectively protect the victim resident from physical abuse by another resident.
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