Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from physical abuse by another resident. The incident involved a resident with severe cognitive impairment who was calling for help, which disturbed his roommate. The roommate, who was cognitively intact at the time, moved across the room and made physical contact with the resident, striking him on the chest and head. This event was witnessed by a CNA, who described the contact as aggressive and stated that the resident was struck with a backhanded motion on the chin and then on the top of the head. The CNA immediately intervened and separated the residents. The clinical record review revealed that there was no documentation of the incident in the resident's record, no notification to the medical provider, and no assessment for injury following the incident. Although both residents were later assessed and found to have no visible injuries, the initial lack of documentation and assessment represented a failure to follow required procedures for reporting and responding to abuse allegations. Interviews with staff confirmed that the incident was reported verbally, but the necessary documentation and immediate medical evaluation were not completed as required. The facility's policy defines abuse as the infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and requires prompt reporting and investigation. Despite the policy, the facility did not substantiate the incident as abuse due to a perceived lack of evidence, even though a staff member witnessed aggressive physical contact. The absence of proper documentation and immediate assessment after the incident contributed to the deficiency.