Failure to Protect Resident from Physical Abuse During Altercation
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident during an altercation over television control in their shared room. Resident 2, whose cognition was moderately intact, deliberately placed his hands on Resident 1's chest and pushed him, causing Resident 1, who had moderately impaired cognition, to fall and sustain a skin tear and abrasion on his left forearm. The incident occurred when Resident 1 changed the television channel using his remote, which also affected Resident 2's television due to the shared control system. There were no staff present in the room at the time of the incident, and the altercation was witnessed by another resident. Interviews and documentation confirmed that Resident 2 admitted to pushing Resident 1 because of the television channel change, and staff acknowledged that the TV remote system allowed one resident's remote to control multiple TVs in the room. The facility's maintenance supervisor was aware of previous complaints about the TV system, but it had remained unchanged. The facility's policy requires protection of residents from all forms of abuse, but this was not upheld in this instance, resulting in physical harm to Resident 1.