Failure to Prevent and Respond to Resident-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from resident-to-resident abuse despite clear warning signs and prior incidents. Resident B, who had diagnoses including schizophrenia, depression, suicidal ideations, and vascular dementia, verbally threatened Resident C on one day, telling her he would kill her if she came into his room. Staff Member 8 overheard this threat and reported it to the Director of Nursing, who instructed her to inform Social Services. When the incident was reported to Social Services, the staff member was asked what she wanted Social Services to do about it. The Administrator later stated she was unaware of this threat when she initially reported the subsequent physical incident and had not yet obtained staff statements. The following day, Resident C, who had a history of traumatic subarachnoid hemorrhage, traumatic brain injury, affective mood disorder, and anxiety, continued to pace the halls, enter other residents’ rooms, rummage through belongings, and disturb other residents, and was described as difficult to redirect and agitated. Around that time, Resident C approached the area near Resident B’s room. Multiple staff interviews indicated that Resident B came out of his room, grabbed Resident C by the neck and shoulder area, twisted her arm behind her back, and pushed her into a geriatric chair in the hallway, shoving her multiple times as she tried to get away. Staff Member 9 intervened and separated the residents, and both Staff Member 9 and Staff Member 17 reported what they witnessed to the Director of Nursing. The incident report and progress note, however, documented the event as Resident B placing his hands on Resident C’s shoulders, turning her around, and slightly pushing her from the back. In a separate but related incident, Resident D, who had a history of traumatic brain injury and anxiety, admitted to pushing her rollator walker into Resident C’s legs because Resident C had entered her personal space. Staff Member 9 reported that she had to separate Resident C and Resident D after Resident D rammed her walker into Resident C’s legs and reported this to the Director of Nursing. An incident report later documented that Resident D made contact with Resident C’s legs with her rollator walker. These events occurred in the context of Resident C’s ongoing behavior of pacing the halls, entering other residents’ rooms, and disturbing them, and demonstrate multiple instances of resident-to-resident physical contact that met the facility’s own definition of physical abuse under its Abuse Prevention Program, which states the facility will not tolerate abuse by anyone, including other residents.
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