Failure to Protect Residents from Abuse During Roommate Altercation
Penalty
Summary
The facility failed to protect the rights of two residents to be free from abuse, as evidenced by an altercation between two roommates. One resident, who had diagnoses including dementia and severely impaired cognition, was involved in a physical altercation with her roommate over a plastic flower. During the incident, one resident slapped the other on the face, and the other responded by shoving her roommate's shoulder. Staff intervened and separated the residents, and a skin assessment was completed with no injuries noted. Clinical documentation and staff interviews confirmed that the altercation was witnessed by staff, who heard a commotion and observed the physical exchange. The residents were separated, and notifications were made to the DON, administrator, and provider. However, the behavioral progress note indicated that the resident's representative and case manager were not notified of the incident. Both residents had care plans indicating a potential for verbal aggression related to dementia, with interventions to assess and anticipate needs, but the altercation still occurred. Staff interviews revealed that the incident was recognized as a form of abuse, with both the LPN and Medication Technician stating that physical contact such as slapping or pushing constitutes abuse. The facility's policies on abuse prevention and resident rights were reviewed, confirming the expectation to prevent all types of abuse. Despite these policies and staff training, the incident occurred, resulting in a failure to fully protect residents from abuse as required.