Failure to Prevent Resident-to-Resident Physical Abuse During Meal Service
Penalty
Summary
The facility failed to protect a resident from abuse by another resident during a breakfast meal. One resident, who had severe cognitive impairment and multiple medical diagnoses including senile degeneration of the brain and diabetes, was attempting to back his wheelchair away from the dining table. In the process, his wheelchair unintentionally bumped into another resident's wheelchair. The second resident, who also had significant medical conditions such as expressive language disorder, Parkinsonism, and hemiplegia, responded by striking the first resident in the right arm with a closed fist. Multiple staff members witnessed the incident, with one CNA observing the resident being hit in the chest and another noting contact to the arm and chest area. Video footage confirmed that the two residents' wheelchairs became entangled, leading to a physical altercation where the second resident hit the first resident in the right forearm. The incident occurred because the first resident was not seated in his usual spot, which contributed to the close proximity and subsequent altercation between the two residents. The facility's policy defines resident-to-resident physical altercations as reportable events and includes actions such as hitting and punching as forms of abuse. The incident was documented in progress notes, witness statements, and a facility reportable event record. Both residents were assessed after the incident, with only slight redness noted on the first resident's wrist and no other injuries reported.