Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident (R1) from physical abuse by another resident (R2). On the morning of the incident, staff members, including a CNA and an RN, heard yelling and cursing coming from the shared room of R1 and R2. Upon entering, staff observed both residents engaged in a verbal altercation. Despite attempts by the CNA to de-escalate the situation and physically intervene by pulling on R2's shirt, R2 managed to push R1 down onto the bed multiple times. The CNA and other staff present were unable to prevent R2 from making physical contact with R1 during the altercation. R1 was described as physically fragile, with a history of liver cell carcinoma, bone neoplasm, spinal fusion, pathological fracture, severe malnutrition, and other significant medical conditions. R1 was wheelchair-bound and cognitively intact. R2, who was significantly larger in stature, also had multiple medical diagnoses but was ambulatory and cognitively intact. Prior to this incident, R2 had demonstrated verbally and physically agitated behavior, including an earlier episode where R2 swung a cane at staff. Both residents had a history of verbal arguments, and R2's care plan noted a risk for abuse/neglect due to agitated behavior, with interventions to observe R2 when in the company of peers. The incident was witnessed by multiple staff members and corroborated by documentation in progress notes and interviews. R2 admitted to pushing R1 and expressed ongoing aggression towards R1 after being removed from the room. The facility's policy affirms the right of residents to be free from abuse and requires the establishment of a secure environment, but in this case, the measures in place were insufficient to prevent the physical abuse of R1 by R2.