Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse during a resident-to-resident altercation. One resident, who had a history of anxiety disorder, moderate cognitive impairment, and behavioral issues such as striking out at others, was involved in multiple incidents of aggressive behavior prior to the altercation. Care plans for this resident included interventions to monitor and document behaviors, analyze triggers, and attempt de-escalation, but these interventions did not prevent the incident. The other resident involved had recently been readmitted with altered mental status and other medical conditions, and had not yet received a BIMS assessment. This resident was noted to be exit-seeking, agitated, and resisting care, with a care plan focused on behavior management and safety. On the day of the incident, both residents were in front of the nurse's station when one resident demanded the other move so he could sit in an empty chair. When the request was not met, the resident struck out and fell, leading to a physical altercation where both residents exchanged blows and kicks. Certified nursing assistants (CNAs) witnessed the event and intervened to separate the residents. The incident resulted in visible injuries, including bruising and skin tears, and was documented by staff through behavior and incident notes, as well as witness statements. Interviews with staff revealed that the facility was short-staffed at the time of the incident, with fewer CNAs present than usual. Staff described the sequence of events and the actions taken to separate the residents and provide care for their injuries. The facility's policy on abuse and neglect emphasizes a zero-tolerance approach and outlines responsibilities for identifying at-risk residents and developing intervention strategies, but the policy was not effectively implemented to prevent this altercation.