Failure to Prevent Resident-to-Resident Physical Abuse Due to Lack of Supervision
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in the assaulted resident being sent to the hospital for evaluation of facial trauma. The incident occurred in the dining room, where a resident with a fractured ankle was using a chair to elevate his leg. Another resident attempted to take the chair, and when told to leave it, physically assaulted the first resident by punching him in the face. At the time of the incident, there was no staff present in the dining room to monitor the residents, despite multiple residents being present in the area. Interviews and record reviews revealed that both residents involved had intact cognition according to their BIMS scores, and neither had care plans addressing susceptibility or predisposition to abuse prior to the incident. Staff statements confirmed that the dining room was not consistently monitored, particularly during shift changes or when staff were occupied with other duties such as charting. The only CNA on duty for the unit reported alternating monitoring duties with nurses, but at the time of the altercation, no staff were present in the dining room. Documentation from the LPN, hospital, and police corroborated the occurrence of a physical altercation, with the assaulted resident sustaining swelling to the left eye and being sent to the hospital for further evaluation. The facility's abuse prevention policy emphasized the need for resident assessment and staff supervision to prevent abuse, but observations and staffing records indicated inadequate supervision in common areas, contributing to the incident.