Failure to Protect Resident from Verbal and Physical Abuse by Another Resident
Penalty
Summary
The facility failed to ensure a resident's right to be free from abuse when one resident was subjected to verbal and physical abuse by another resident. The incident involved a resident with dementia, muscle weakness, and cognitive communication deficit, who was severely cognitively impaired according to the BIMS score. This resident was found with a bruise and skin tear on the left upper arm after another resident, also severely cognitively impaired and diagnosed with Alzheimer's, psychotic disorder with delusions, and Parkinson's disease, grabbed the resident's arm during an altercation. The aggressor was heard making a profane demand for toilet paper before physically grabbing the other resident, resulting in injury. Staff documentation and interviews confirmed that the incident was witnessed by a CNA, who reported hearing the verbal outburst and then observed the physical contact. The CNA intervened by instructing the aggressor to let go, after which the residents were separated. The injured resident's arm was assessed, cleaned, and treated according to protocol. Progress notes indicated that the injured resident was later found sleeping without acute distress, and there was no evidence of prior physical or verbal behaviors towards others in the recent assessment period for either resident. The facility's policy on freedom from abuse, neglect, and exploitation emphasizes the right of each resident to personal privacy and protection from abuse. The policy also outlines the need for identifying and intervening in situations where abuse is more likely to occur, including ensuring adequate and competent staffing. Despite these policies, the incident occurred, and staff interviews revealed expectations for immediate intervention and reporting in cases of resident-to-resident altercations.