Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with moderately impaired cognition and a history of hemiplegia, dementia, and anxiety disorder was not protected from abuse by another resident. The incident took place in the dining room, where three CNAs were present. During the meal, another resident with severely impaired cognition due to metabolic encephalopathy and Alzheimer's disease became physically aggressive, pushing the first resident's plate onto her chest and lap. The affected resident reported feeling upset by the incident. Staff interviews confirmed that the altercation was witnessed, and the facility's policy states that residents must be protected from abuse by anyone, including other residents. Despite this, the event resulted in a failure to ensure the resident's right to be free from abuse, as required by federal regulations.
Plan Of Correction
Residents were separated immediately at the time of the incident and Resident 21 was removed from the dining room. All residents who have an altercation have the potential to be affected by the same deficient practice. Any residents who have an altercation will be separated immediately and reported accordingly. DSD in-serviced staff on 07/08/25 on Abuse Policy and ways to prevent altercations. DSD to observe the behavior of Resident 12 in the dining room weekly x 4 weeks, monthly x 1 month to ensure no altercations occur and residents feel safe. Any findings out of compliance will be brought to the attention of the Administrator and addressed immediately. All findings will be reported to the QA Committee. Corrective action will be achieved and sustained by 07/24/2025.