Failure to Prevent Resident-to-Resident Abuse During Unsupervised Smoking Break
Penalty
Summary
Two residents were involved in a physical and verbal altercation during a smoking break on the facility's patio. Both residents have documented histories of aggression and combative behavior, as indicated in their care plans and abuse risk reviews. During the incident, one resident hit the other in the face, and the other retaliated by throwing an open milk carton, resulting in milk being spilled. Both residents exchanged insults and physical contact, with no staff present outside at the time to supervise the interaction. The altercation was only addressed after it had occurred, when a psychosocial aide/social service assistant intervened. The incident was not reported to the police, and one of the residents was sent to the hospital for evaluation. Both residents have intact cognition, as shown by their BIMS scores, and have diagnoses including schizophrenia, major depressive disorder, chronic obstructive pulmonary disease, and end stage renal disease. The facility's policy affirms residents' rights to be free from abuse and neglect, but the lack of staff supervision during the smoking break allowed the altercation to occur without immediate intervention.