Failure to Protect Resident From Abuse and Inadequate Behavior Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident in the dining room. On the date of the incident, a female resident seated in her wheelchair in the dining room was approached by another resident who began pushing her wheelchair. The seated resident extended her right hand and asked the other resident to stop, at which point the other resident grasped the top of her right hand, causing a skin tear on the dorsal right hand. During the same timeframe, the aggressor resident was also observed on camera grabbing and shaking other residents’ wheelchairs in the dining area. Seven staff members later stated they did not witness the actual altercation and only became aware when the injured resident called for help or was observed bleeding. The injured resident had a history of generalized muscle weakness, need for assistance with personal care and ambulation, major depressive disorder, and type 2 diabetes, with a BIMS score indicating moderate cognitive impairment. She reported to the surveyor that a man in the building had “stabbed” her hand by digging his fingers between her thumb and index finger, and she stated that she did not feel safe and was staying in her room because that was where she felt safe. During a subsequent joint visit with the social worker and surveyor, she again expressed anger that the man was still “roaming the facility,” stated she felt unsafe outside her room, and said she had a plan to fight back if he came near her. Wound assessments documented a painful right-hand skin tear with sanguinous/serosanguinous drainage that persisted over multiple assessments. The resident who caused the injury had diagnoses including dementia, psychotic disorder with delusions, mood disorders, generalized anxiety disorder, and type 2 diabetes. His behavior care plan, initiated months earlier, documented that he could be combative, wander into other residents’ rooms, and hit out at other residents. The care plan goal was that he would have no evidence of behavior problems, with an intervention for caregivers to provide opportunities for positive interaction when passing by. Although the care plan showed a revision date after the altercation, it did not add any specific interventions to address his combativeness or to protect other residents from harm, and the behavior care plan was not updated following the resident-to-resident altercation. This failure to revise and individualize the behavior care plan, in the context of known behavioral risks and an actual physical altercation resulting in injury, constituted the cited deficiency in protecting residents from abuse.
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