Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse when both, while in their wheelchairs in a hallway, engaged in a physical altercation. One resident grabbed the other's arm, and both pushed against each other's hands and arms, resulting in abrasions that required first aid and daily wound care. The incident was witnessed by a CNA, who observed both residents intentionally grabbing and applying pressure to each other's arms, but could not determine who initiated the contact. One of the residents involved had a history of encephalopathy, heart disease, and vascular dementia, and was assessed as able to make himself understood and requiring moderate assistance with most activities of daily living. The other resident had diagnoses including type two diabetes mellitus, schizoaffective disorder, and reduced mobility, with severely impaired cognition and complete dependence on staff for most activities of daily living. Both residents sustained skin abrasions as a result of the altercation, with one resident requiring wound care for two separate injuries and the other for one. Despite the facility's policy stating that residents must be protected from abuse by anyone, including other residents, the staff did not prevent the altercation. Interviews with the Administrator and DON revealed that they did not consider the incident to be abuse, instead characterizing it as an accident or self-protective behavior. However, the documented evidence and staff observations indicated that both residents were subjected to physical abuse while under the care of the facility.