Resident-to-Resident Abuse Incident
Penalty
Summary
Highlands Rehabilitation And Healthcare Center was found to be non-compliant with the requirement to protect residents from abuse, as evidenced by an incident involving two residents. Resident 1, who was admitted with unspecified dementia, was found on the floor with a fracture to her right arm after reportedly being pushed out of bed by her roommate, Resident 2. Resident 1 expressed fear and pain following the incident, which was unwitnessed by staff. The facility's documentation confirmed the injury and Resident 1's statement about being pushed. Resident 2, who has a diagnosis of bipolar disorder and was assessed with intact cognition, initially denied involvement but later admitted to pushing Resident 1. The incident occurred after Resident 2 was observed leaving the room and later admitted to the police and staff that she had pushed her roommate. The facility responded by moving Resident 2 to a different room and placing her on 15-minute checks for safety. Despite these measures, the facility failed to prevent the abuse from occurring. Interviews with staff revealed that Resident 2 had been acting differently due to the recent death of another resident she was close to. The Director of Nursing noted that Resident 2 was attention-seeking and initially denied the incident. The facility's investigation included witness statements from staff who confirmed Resident 2's admission of pushing Resident 1. The report highlights the facility's failure to protect Resident 1 from physical abuse by another resident, as required by federal and state regulations.
Plan Of Correction
1. R1 remains in the facility. Sling intact to right arm and pain controlled. She continues to have no recollection of the events and is happy in her new room. Social work visits completed. R2 remains in the facility. Medical follow up complete. ABT completed. Psych services continue to follow. Social work visits completed. She remains happy in her new room. 2. Residents on 3rd floor with a BIMS score of 8 or higher were interviewed/assessed for potential abuse. 3. DON/Designee reeducated abuse policies, investigation procedure and documentation process. Nurse aides and Licensed Nurses have been educated on documenting behaviors. 4. DON/SW/Designee will perform random audits of 5 resident's behaviors in nursing notes or EMAR/ETAR to ensure care plans updated weekly X 8, then monthly X 1. Results will be brought to QAPI.