Failure to Prevent Resident-to-Resident Physical Abuse by a Behaviorally Challenging Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a vulnerable adult from physical abuse by other residents despite ongoing behavioral concerns. Facility policy defined all adults in the facility as vulnerable adults and required systems to identify residents at risk of abusing others, continual assessment and care planning, and implementation of measures to protect residents from abuse. Resident 3 had a documented history of wandering into other residents’ rooms and intrusive behaviors. On one occasion, Resident 3 entered another resident’s room and would not leave, resulting in the other resident pushing Resident 3 out of the room, causing Resident 3 to fall face down and sustain a hematoma above the left eye. The care plan included short-term 15‑minute checks and later temporary interventions such as redirection, music, snacks, toileting, 1:1 time, and PRN psychotropic medication, but no long‑term interventions were initiated to address the ongoing risk of resident‑to‑resident altercations. Progress notes over the following weeks documented repeated episodes of Resident 3 wandering into other residents’ rooms, being invasive, touching other residents on the chest and head, and becoming physically aggressive toward staff. On a later date, staff responded to residents screaming for help and found Resident 3 in another resident’s room; the resident in the room reported that Resident 3 had hit and choked them while they were sitting in their wheelchair. On another occasion, Resident 3, while in an activity room, walked over and hit one resident on the top of the head and then pursued and hit another resident in the face. Interviews with the Facility Administrator and the MDS Coordinator revealed that 1:1 supervision for Resident 3 occurred only at times and that long‑term interventions such as continuous 1:1 supervision were not implemented, despite recognition that Resident 3’s behaviors placed other vulnerable adults at risk of abuse. These actions and inactions resulted in the facility’s failure to ensure that Resident 3 and other residents were free from physical abuse as required by policy and regulation.
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