Failure to Prevent and Report Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent a resident-to-resident physical assault, resulting in one resident being struck in the face with a shoe by another resident. The assaulted resident sustained a purple discoloration to the right eyelid and petechia above the eyebrow. The incident was reported by the injured resident to both the Assistant Administrator and her son, and photographic evidence of the injury was provided. The progress notes indicated a verbal altercation between the two residents, after which the aggressor was relocated to another room. However, there was no documentation in the medical record regarding the injury, and the injured resident was alert and oriented at the time of the survey. The Assistant Administrator acknowledged being informed of the incident and observing the injury but did not report the injury of unknown origin to the State Department, nor did he initiate an investigation into the allegation of physical assault. He also did not consult the Administrator for guidance. The Administrator was unaware of the injury and confirmed the lack of documentation and reporting. The facility's abuse policy affirms residents' rights to be free from abuse, neglect, and mistreatment, but the policy was not followed in this instance.