Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, as evidenced by a verbal and physical altercation between them. One resident, a female with emphysema, hypothyroidism, and liver disease, and a history of conflictual behavior and susceptibility to abuse, was involved in a dispute with a male resident who has a vertebra fracture, neurogenic bowel, anxiety disorder, depressive disorder, and angina pectoris, and is also care planned as susceptible to abuse. During the incident, the male resident threw water on the female resident during a verbal altercation, and both exchanged derogatory and offensive language. The altercation was witnessed by an LPN, who separated the residents and reported the incident to the administrator/abuse prevention coordinator. The incident was also reported to the police. Both residents had documented histories of behavioral issues, including verbal threats, use of profanity, and difficulty coping with stress. The facility's abuse prevention policy prohibits and aims to prevent resident abuse, neglect, and mistreatment, but the altercation and subsequent investigation revealed that the facility did not ensure the right of these residents to be free from abuse. The incident was documented in progress notes and an abuse prevention investigation, with both residents expressing that they felt safe after the event, but the deficiency centers on the facility's failure to prevent the abusive interaction from occurring.