Unwitnessed Resident-to-Resident Altercation Resulting in Injuries
Penalty
Summary
A resident with dementia and behavioral disturbances, who was unable to complete a mental status assessment, was involved in an unwitnessed altercation with another resident diagnosed with dementia and behavioral disturbances but who was cognitively intact. The incident occurred when the first resident entered a room and got into bed, where the second resident and another individual were present. The second resident attempted to remove the first resident from the bed, began yelling, and physically tried to pull the resident out. During the altercation, the first resident sustained a lump and redness to the left eye, while the second resident later exhibited edema and an acute fracture to the right hand. The facility's investigation revealed that the event was not witnessed by staff, and the only resident witness was unable to recall details due to advanced dementia. Interviews with both involved residents indicated that the second resident admitted to putting hands on the first resident but did not recall the specifics, while the first resident reported being struck in the eye. The facility's policy requires prompt reporting and thorough investigation of abuse or suspected abuse, including resident-to-resident altercations, but the incident was not observed by staff and relied on post-incident interviews and assessments.