Failure to Implement Preventive Measures After Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from resident-to-resident physical abuse and to implement preventive measures after incidents. Facility policy states residents have the right to be free from abuse, including physical abuse, and that the abuse prevention program must protect residents from abuse by anyone, including other residents, and implement measures to address factors that may lead to abusive situations. Despite this, the facility did not develop or update behavioral care plans with preventive interventions following two separate resident-to-resident altercations on the men’s secured unit, and staff were not provided with new techniques beyond immediate separation of the involved residents. In the first incident, a cognitively intact resident with dementia and a history of frequent physical and verbal behavioral symptoms struck another resident in the face with a soda can in the men’s secured unit dining area. The victim, who had severe cognitive impairment, dementia with behavioral disturbance, and no documented behavioral symptoms on the most recent MDS, sustained a skin tear and bruising near the left eye. The facility’s investigation confirmed that the assailant resident made contact with the victim’s face using a soda can after a conflict over trash, and that the contact constituted substantiated abuse. The behavioral care plan for the assailant was revised only to reflect that an altercation had occurred and that staff de-escalated his aggressive mood by returning him to his room, but it did not include any new preventive interventions to avoid recurrence of aggression toward other residents. In the second incident, a resident with severe vascular dementia, behavioral disturbance, and a history of physical and verbal aggression toward staff made contact with another resident’s head in the hallway after both became verbally aggressive. The victim had moderate cognitive impairment, dementia with behavioral disturbance, bipolar disorder, and no prior documented behavioral symptoms on the MDS, and reported that the other resident cursed at him and then hit him, causing the aggressor to fall. The facility’s investigation acknowledged that the aggressive resident had a history of behaviors that could be triggered by feeling rushed, loss of control, unfamiliar staff, changes in routine, or unmet needs, and that without appropriate interventions his behaviors could escalate and place him and others at risk. However, there were no updates to the aggressive resident’s behavioral care plan to address aggression toward other residents, and no new interventions were added to prevent further recurrence. Staff interviews confirmed that CNAs were only told to keep the involved residents separated and were not given additional prevention techniques, and an LPN reported not being informed about recent altercations on the unit, limiting her ability to monitor and separate residents at risk of conflict.
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