Resident-to-Resident Physical Altercation Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident was physically assaulted by their roommate, resulting in significant injuries. The incident involved two residents, both with complex psychiatric and cognitive diagnoses, including schizophrenia, major depressive disorder, and dementia. On the day of the incident, one resident approached the other's bed and began making the bed while the other was still sleeping. This led to a confrontation where one resident grabbed the other's hair, and the other responded by hitting and scratching, resulting in a closed head injury and a nasal bone fracture for one of the residents. Both residents sustained visible injuries, including scratches, bleeding, and pain. Staff, including a CNA and an LVN, responded to the altercation after hearing yelling and screaming from the room. Upon entering, they observed the residents physically engaged and separated them. The injured resident was subsequently transferred to a hospital for evaluation and treatment, where imaging confirmed a nasal bone fracture and a closed head injury. The other resident was later transferred to another hospital on a psychiatric hold due to ongoing aggressive behavior. The report details that both residents had a history of mental health and cognitive impairments, and staff interviews indicated that residents with aggressive behaviors should be closely monitored to prevent such incidents. The facility's policy emphasized the commitment to protecting residents from abuse by anyone, including other residents. However, the actions and inactions leading up to the event, including the lack of effective monitoring or intervention prior to the altercation, resulted in a failure to ensure the right of residents to be free from abuse and physical harm.
Plan Of Correction
CORRECTIVE ACTION: On 3/20/25, Resident 4 was assessed by the licensed nurse, initial treatment was provided, Analgesic was provided for pain and was transferred to a General Acute Care Hospital for further evaluation. Resident 4 returned the same day and room change was initiated. Treatment for scratches to face continued until resolved on 3/31/25. Resident did not have any complaints of pain upon return and throughout the stay at the facility. On 3/21/25 and 3/24/25, Social Services Director conducted a room visit to Resident 4 and Resident 4 had no concerns regarding care or safety. On 3/21/25, Psychiatrist consult was conducted and Resident 4 had no new onset of any Psychiatric concern and stated she feels safe in the facility. On 4/9/25, x-ray of nose was ordered but resident refused. On 4/10/25, x-ray was re-offered but resident still refused stating she does not have any pain. Risks and benefits explained but still refused. Primary Physician and Responsible Party was notified. On 3/20/25, Resident 5 was assessed by the licensed nurse, initial treatment was provided, Analgesic was provided for pain, one-on-one sitter was initiated and was transferred to a General Acute Care Hospital for further evaluation. Resident 5 returned to the facility the same day with no major injuries noted. On 3/20/25 and 3/21/25, Social Services Director conducted a room visit to Resident 5 and Resident 5 had no concerns regarding care or safety after she was separated from Resident 4. Resident 5 continued to have one-on-one sitter until transferred to another facility per Resident 5's request. Resident 5 will not return to the facility. On 3/21 and 3/24, all staff was provided in-servicing on Resident-to-resident altercation/abuse prevention, reporting and investigation. On 4/10/2025, an All Staff meeting was conducted with outside resources to in-service on behavior management of residents. **IDENTIFYING OTHER RESIDENTS AT RISK** All residents had potential for harm due to the deficient practice. On 4/10/25, facility audited residents with a history of aggressive behavior and 16 residents were identified. 2 of 16 identified residents had an altercation on 3/30/25 that was immediately de-escalated by staff with no negative outcome. On 4/10/25, SSD/designee interviewed 48 residents with capacity to make decisions and make needs known to ensure resident safety and roommate compatibility. 2 residents who verbalized concerns with roommates were moved to another room per resident's request. **SYSTEMIC CHANGES** Hallway Monitor Program (24/7 monitoring) was initiated on 3/29/25. All Hallway Monitoring Aides have undergone Skills Competency conducted by DSD/Designee. Monitoring aides will do rounds every two hours to identify residents with potential escalating behaviors that could lead to aggression. Findings will be logged onto a Hallway Monitor Form and will be reported and addressed accordingly. A certified Management Assaultive Behavior trainer resource initiated an in-person training on 4/10/25 to staff regarding preventing resident-to-staff and resident-to-resident altercation by identifying potential behaviors and how to de-escalate situations that may lead to altercation. Psychology visits will be increased to weekly at minimum for all residents with a history of aggressive behavior and will be referred to a Psychiatrist as needed. **MONITORING EFFECTIVENESS** The SSD/designee will report concerns or issues related to the deficient practice to the DON and/or Administrator for follow-up. Staff will also be encouraged to identify trends and vocalize concerns related to the deficient practice by utilizing the Administrator's open door policy and by participating in providing feedback at the mandatory monthly All Staff Meeting. Reports and findings will be submitted to the QAA Committee for further review and recommendations. Submissions to the committee will be monthly for a period of 3 months or until full compliance is achieved.