Failure to Assess Abuse Risk and Supervise Residents, Leading to Resident-to-Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to accurately assess a resident’s risk of abuse and to adequately supervise residents to prevent resident-to-resident physical abuse, resulting in one resident physically assaulting another. The facility’s Abuse and Retaliation Prevention Program Policy states that residents have the right to be free from abuse, neglect, exploitation, and mistreatment, and that staff will identify residents with increased vulnerability for abuse or behaviors that might lead to conflict through admission assessments, care plans, and MDS assessments. Despite this policy, a male resident with severe cognitive impairment and diagnoses including vascular dementia with behavioral disturbance, schizoaffective disorder, and delusional disorder was not effectively assessed or managed for behaviors that could lead to conflict or abuse. On the night of the incident, an RN heard yelling from the middle hall and found the cognitively impaired male resident wheeling out of a female resident’s room. The female resident reported that the male resident had crawled on top of her in bed and punched her on the right side of her face three times, after which she punched him back and pushed him off. Another resident in the room reported being awakened by the female resident yelling for help and observed the male resident crawling on top of the female resident in bed, with the female resident trying to get him off and striking him until he got back into his wheelchair. The RN documented that the male resident was showing signs of increased mania that night and was capable of transferring himself from his wheelchair into the female resident’s bed. The male resident was subsequently sent to the emergency department, where records noted he had allegedly hit another resident earlier that day. The female resident, who was cognitively intact with documented anxiety and insomnia, later described that the male resident had repeatedly pursued her for a relationship, followed her in the hallways, and on one occasion attempted to touch her breasts, which she blocked and reported to staff. She stated that on the night of the incident she awoke to the male resident rubbing her stomach while kneeling on her bed, and that when she yelled at him to get off, he began punching her in the head, causing pain and leaving her feeling stunned and traumatized. She reported ongoing fear of men, changes in how she dressed at night, and the need for therapy to cope with what occurred. Her psychiatric APN documented that this event triggered increased anxiety, fear, restlessness, and self-blame, leading to medication adjustments for anxiety. Despite these allegations and documented anxiety, her care plan did not address the abuse allegations or include interventions to protect her from the male resident or to address her increased anxiety and fear. Additionally, an Abuse Risk Review completed by the Social Service Director inaccurately documented that she had not experienced or made allegations of any type of abuse since the prior review, and therefore no further care plan recommendations were made, reflecting a failure to recognize and incorporate the abuse incident into her assessment and care planning.
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