Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, as required by its Abuse Prevention and Prohibition Program. One resident with severe cognitive impairment and behavioral issues, including hallucinations and a history of behavioral problems, tipped over the wheelchair of another resident who also had severe cognitive impairment and physical limitations due to Parkinson's Disease and dementia. This incident occurred while the resident was being wheeled toward the dining room, resulting in the other resident falling and hitting her head on a doorway, causing a minor skin tear and bleeding. Staff observations and interviews confirmed that the incident was witnessed by a CNA, and documentation indicated that the resident who caused the incident was not adequately monitored to prevent such behavior. The facility's policy states that all residents have the right to be free from abuse and that the facility is responsible for protecting residents from abuse by anyone. The DON acknowledged that the resident was not monitored sufficiently to prevent the incident, which resulted in physical harm to another resident.