Failure to Protect Residents From Abuse and Incomplete Post‑Incident Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse during and after a resident-to-resident altercation. One resident with hemiplegia, hemiparesis following cerebrovascular disease, and anxiety disorder, and with moderately impaired cognition (BIMS score 12), was involved in a physical altercation with another resident diagnosed with paranoid schizophrenia and systemic lupus erythematosus, whose cognition was severely impaired (BIMS score 5). According to the SBAR and interviews, the incident occurred in the smoking area when the cognitively impaired resident asked the other resident for a cigarette and lighter, was refused, and then struck the resident on the right side of the face. Witness accounts varied slightly regarding whether the first resident swung his arm or elbowed the second resident, but all accounts and the facility’s own investigation confirmed that physical contact and a resident-to-resident altercation occurred. The facility did not complete required 72-hour monitoring following this change of condition for either resident. Documentation showed that for the first resident, monitoring was recorded on the day of the incident during evening and night shifts, and on the next two days for all shifts, but there was no evidence of any 72-hour monitoring on the third day for any shift. For the second resident, monitoring was documented on the day of the incident during evening and night shifts, and on the following day for morning and evening shifts, but not for the night shift. On the third day, monitoring was documented only for the morning shift, with no evidence of monitoring for the evening and night shifts, and no monitoring at all on the fourth day. Nursing staff and the DON stated that any change in condition required 72-hour monitoring every shift, documented in progress notes, and emphasized that this was especially important for residents involved in an abuse allegation. The facility also failed to implement and maintain protective supervision measures in the smoking area after the altercation. The second resident’s care plan noted involvement in the incident and that he had hit the other resident on the right side of the face, with staff expected to continue to monitor the smoking area. However, a smoking observation/assessment completed later that same day indicated that this resident could smoke independently without supervision and that the IDT had decided he may smoke without supervision. Observations on subsequent days showed this resident smoking outside without staff present and sitting unattended in the smoking area. Staff interviews indicated that, although there was a brief period when more staff were outside to supervise, this increased supervision only lasted about a day, and the Activities Director reported that staff were told to supervise the two residents when smoking but stated they did not have the manpower to always be outside and could not prevent residents from going out to smoke outside of scheduled smoking times. The DON acknowledged that the smoking assessment allowing unsupervised smoking conflicted with the recent abuse allegation and the facility’s stated expectation of supervised smoking times.
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