Failure to Protect Residents From Physical Abuse and Incomplete Documentation of Incidents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse by another resident and to ensure accurate and complete documentation of such incidents. One resident with bipolar disorder, depression, delusional disorder, schizophrenia, heart failure, seizures, unspecified psychosis, and a BIMS score of 12 (moderate impairment) was identified as the aggressor in multiple resident-to-resident incidents. The facility’s abuse policy states that residents have the right to be free from abuse, neglect, exploitation, misappropriation of property, or mistreatment, and that residents involved in possible abuse are to be immediately protected. Despite this, the resident’s care plan only addressed verbally abusive behavior and did not reflect physical aggression toward others. In one incident, a cognitively intact resident with anxiety, COPD, asthma, hypertension, substance abuse, and a left above-knee amputation reported that when she shared a room with the aggressive resident, the aggressive resident came into the room, hit her from behind in the jaw, and knocked items off her bedside table. The resident stated she was concerned due to her wheelchair dependence. A CNA heard commotion and heard the resident report to an RN that she had been hit. The RN later stated that the resident reported the aggressor had brushed past and bumped her shoulder and acknowledged that this contact was a form of abuse. However, review of the electronic health record for the resident who reported being hit showed no documentation of the incident in her progress notes, indicating a failure to document and formally recognize the reported physical abuse. In a separate incident, another resident with chronic respiratory failure, COPD, congestive heart failure, pulmonary embolism, hemiplegia, hemiparesis, and a BIMS score of 12 (moderate impairment) reported that the same aggressive resident entered his room, asked for money, and, after being refused, cursed at him and threw a water pitcher, striking him in the side of the face and covering him with water and ice. This resident reported the event to the nurse on duty and stated he was not physically hurt but was emotionally affected. Progress notes for both residents documented that the aggressive resident entered the room, begged for candy, and threw a pitcher of ice water into the resident’s face. Despite these documented and reported incidents, the administrator and DON stated they were not aware of the water-throwing incident or the reported hitting incident until much later, demonstrating a breakdown in timely reporting to facility leadership and failure to ensure residents were free from physical abuse.
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