Failure to Prevent and Protect Resident from Abuse Resulting in Injury
Penalty
Summary
A deficiency occurred when the facility failed to prevent and protect a resident from resident-to-resident abuse, resulting in the resident sustaining a left ankle fracture. The incident began when the resident refused to lend a Bluetooth speaker to another resident, leading to a verbal altercation with a second resident who then used his electric wheelchair to ram into the first resident, knocking him to the floor and running over his leg. Staff intervened only after the second resident attempted to run over the resident again. The initial staff response was limited to asking if the resident was okay, and no immediate assessment or vital signs were taken at that time. The resident later reported pain in his foot to a nurse, but there was no documentation of a thorough assessment or physician notification prior to the resident experiencing a fall in his room due to increased pain. After the fall, emergency services were called, and the resident was diagnosed with a closed bimalleolar fracture of the left ankle. The documentation failed to show that the nurse recorded the resident's complaint of pain, the assessment performed, or the notification to the physician before the fall occurred. The resident's care plan indicated a low risk for aggression, while the second resident had a documented history of behavioral issues and aggression towards peers and staff. Despite this, the second resident continued to have access to the area where the injured resident was relocated, and there was no evidence of effective interventions to prevent further contact or abuse. The facility's policies and residents' rights documents emphasize the prohibition of abuse and the requirement to protect residents from harm, which was not upheld in this case.