Resident Assaulted by Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when another resident physically assaulted him. Resident 1, who has moderate memory impairment and was admitted with pancytopenia, was punched in the head by Resident 2 during a smoke break. This incident resulted in Resident 1 falling from his wheelchair and sustaining an abrasion to his left elbow. The altercation occurred despite the presence of a Restorative Nursing Assistant (RNA) who was supervising through a window but was unable to intervene in time. Resident 2, who has severe memory impairment and was admitted with unspecified dementia and anxiety, was identified as the aggressor. Prior to the incident, Resident 2 had been accusing Resident 1 of stealing money, a situation that staff were aware of. The Director of Nursing (DON) acknowledged that the altercation violated Resident 1's right to be free from abuse, as outlined in the facility's Abuse Prevention and Prohibition Program policy. This policy emphasizes that each resident has the right to be free from mistreatment, neglect, and abuse.
Plan Of Correction
F600 Free from Abuse and Neglect How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: A) On 03/14/2025 Resident #1 was moved to a different hallway of the facility. B) Resident #1 monitored elbow abrasion and for delayed injury doctor will be notified of any changes. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: C) DON completed an audit on 03/26/2025 of residents who pose a risk for altercation. All residents have the potential to be affected by this deficient practice. No other areas were identified with having this same deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: D) An in-service was initiated by facility DSD on 03/26/2025 to licensed staff regarding the importance of preventing abuse and reporting abuse. E) Nursing staff to monitor resident #1's abrasion and for delayed injury for the next 7 days and report any changes to the doctor. How the facility plans to monitor its performance to make sure that solutions are sustained: F) Nursing staff to monitor resident #1's abrasion and for delayed injury for the next 7 days and report any changes to the doctor. G) IDT team will review COC the following day during the five day a week clinical morning meeting to ensure abuse prevention efforts were made ensure reoccurrence does not. All non-compliance issues identified will be brought forth to the daily morning manager meeting and corrected immediately and reported to the Administrator for review, validation, and resolution. Administrator will do trending/analysis and will report quarterly to the QAPI Committee for further evaluation and/or recommendations.