Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to follow its abuse policy and did not protect residents from abuse, resulting in a physical altercation between two residents. Both residents involved had documented histories of verbal and physical aggression, as well as care plans identifying them as at risk for abusive behaviors. On the day of the incident, one resident attempted to obtain juice from a cart after lunch, which led to a verbal exchange with another resident. The situation escalated when one resident threw a cup of juice at the other, who then responded by striking the first resident in the face. Staff interviews and observations revealed that the altercation occurred in a common area near the dining room, with both residents in wheelchairs. Housekeeping staff witnessed the incident, while the assigned CNAs were providing care to other residents and did not hear the commotion. An LPN became aware of the situation only after hearing a disturbance and intervened after the physical contact had already occurred. The injured resident was observed with a swollen, bruised, and lacerated left eye following the incident. Both residents had care plans and risk assessments indicating a history of aggression and potential for abusive behavior. Despite these documented risks, staff were not present to prevent or immediately intervene in the altercation. The facility's initial abuse investigation report to the State Surveying Agency inaccurately noted that no physical contact had occurred, despite evidence and witness statements to the contrary. The facility's abuse policy affirms residents' rights to be free from abuse, but this policy was not effectively implemented in this instance.