Failure to Prevent and Individualize Care for Repeated Resident-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse, specifically resident-to-resident physical altercations, and to ensure adequate supervision, oversight, and effective, individualized care plan interventions. The facility’s Abuse Prevention Plan defines resident-to-resident altercations as incidents where a resident willfully inflicts injury upon another resident and includes physical acts such as hitting and slapping as abuse. Despite this policy, multiple incidents occurred in which residents physically struck other residents, indicating that processes to prevent such abuse were not effectively implemented. In one incident, a resident propelling himself in a wheelchair down the hall was kicked in the back of his wheelchair by his roommate, who then struck him in the jaw with a closed fist. Staff intervened and separated the residents, and nursing assessed the victim with no injuries noted and no reported pain. The aggressor’s care plan documented a diagnosis of restlessness and agitation, use of an antipsychotic medication, and a history of a physical altercation with the same roommate due to agitation, indicating known behavioral risks that required targeted interventions. In separate incidents, a resident with severe cognitive impairment was physically struck on two occasions by other residents with moderate cognitive impairment. During an activity, after one resident knocked clothing items from a table, another resident became visibly distressed, moved her wheelchair next to her, verbally admonished her, and slapped her on the cheek, resulting in mild redness but no reported pain or psychosocial distress. On another occasion, after one resident told the cognitively impaired resident to stop singing and to shut up, staff briefly redirected and then left to assist another resident; upon return, a different resident was found in the cognitively impaired resident’s room, pushing her chair, kicking her leg, and slapping at her hand, after which the cognitively impaired resident slapped back. Assessments again noted no physical injuries or expressed distress. The care plans for the involved residents all contained identical, non-individualized interventions related to altercations and a generic problem statement about being vulnerable adults needing assistance to remain safe, without specifying what interventions staff should implement if residents became violent or physically aggressive. These omissions contributed to repeated resident-to-resident abuse and the facility’s failure to protect residents from abuse.
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