Failure to Prevent Resident-to-Resident Physical Altercation
Penalty
Summary
The facility failed to follow its abuse policy for two residents when staff did not immediately intervene during an altercation between them. According to staff interviews and documentation, a certified nurse aide observed one resident wandering and redirected her to sit near the nurses station. Another resident approached, and after a brief verbal exchange, both residents began physically striking each other. The staff member intervened only after the altercation had started, and both residents sustained scratches and abrasions to their faces as a result. Wound assessments and nursing notes confirmed that both residents had superficial facial injuries, which were treated with first aid and monitored. The incident occurred in a dementia unit, and staff reported no prior history of altercations between these two residents. The facility's abuse policy prohibits all forms of abuse and requires the establishment of an environment that prevents mistreatment, but in this instance, staff did not act quickly enough to prevent physical harm between residents.