Failure to Prevent Resident-to-Resident Physical Abuse Involving Rehabilitation Equipment
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when one resident struck another in the face with a rehabilitation dowel. The incident occurred when one resident, who was cognitively intact, was lying in bed watching television. His roommate became agitated over the television volume, verbally confronted him, and then physically assaulted him with a dowel. The assaulted resident experienced pain, swelling, and difficulty chewing as a result, and reported feelings of anger following the event. Documentation and interviews confirmed that the aggressor had a care plan in place for potential behavioral disturbances related to a diagnosis of schizoaffective disorder, with a history of physical aggressiveness and combativeness. The care plan included interventions to monitor for aggressive behaviors. Despite this, the resident was able to obtain a rehabilitation dowel without staff supervision, which was later confirmed by the occupational therapist to be against facility policy, as residents should not have access to such equipment without staff present. Staff interviews and medical record reviews indicated that the altercation was witnessed by a CNA, who intervened and confiscated the dowel. The facility's investigation substantiated that the resident was struck, and the physical evidence matched the account given by the resident. The facility's policies required the prevention of all types of abuse, but the lack of supervision and control over rehabilitation equipment contributed to the occurrence of this physical abuse.