Failure to Prevent Resident Possession and Use of Potential Weapons
Penalty
Summary
The facility failed to maintain a safe environment and provide adequate supervision when a resident was able to possess and use multiple objects that could be used as weapons. One alert and oriented resident reported that another alert and oriented resident held a knife to her neck and threatened her, causing her to feel scared. A CNA stated she heard the threatening incident and observed the resident with the knife standing over the other resident. Staff reported that on the same night, a knife, drill, hammer, and lighters were found in the threatened resident’s room, and that the resident who made the threats also threatened to burn down the facility before being transferred to the hospital. The following day, a CNA, under direction from the DON, searched the threatening resident’s room and found a taser and pocketknife under the bed, and reported that a hammer and drill had also been found there the previous night. The threatening resident, who was alert and oriented, later stated she kept a hammer, drill, and pocketknife in her room for protection. Surveyors observed a pink and black electric drill, a pink and black hammer, scissors, razor blades, and lighters in the medication room, and a metal folding utility-type knife in the Administrator’s desk, which the Administrator confirmed belonged to the resident who had made the threats and had been confiscated after the incident. The Administrator acknowledged that residents having such items in the facility made it unsafe. Review of the resident’s records showed a prior care plan for maladaptive behaviors that may detrimentally affect others, but there was no care plan focus on aggressive behaviors or on the resident’s possession of objects that could be used as weapons. Another resident’s records showed intact cognition and a care plan for risk of alteration in mood and psychosocial well-being with an intervention to provide a calm and positive environment. The facility’s policy on a homelike environment stated that the environment and furnishings should be safe, clean, and comfortable.
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