Failure to Prevent and Monitor Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident during a supervised smoke break. One resident was verbally aggressive, using foul racial slurs and loud language directed at another resident and others present. The situation escalated when the verbally targeted resident struck the verbally aggressive resident above the right eyebrow, resulting in a superficial skin tear. Staff present in the area were unable to intervene in time to prevent the physical altercation, but responded immediately after the incident to separate the residents and provide assessment. The facility's policies require monitoring and documentation following any change in condition, including incidents of abuse or altercations. After the altercation, there was a physician's order to monitor the resident who struck the other for signs and symptoms of emotional distress every day shift for 14 days. However, the facility failed to provide documented evidence of continued monitoring and assessment by licensed nurses for this resident as required by both facility policy and the physician's order. Interviews with staff confirmed that the required monitoring was not completed post-incident. Both residents involved had significant psychiatric histories, with one having schizoaffective-bipolar disorder and the other diagnosed with schizophrenia and moderate cognitive impairment. The care plan for the resident who struck the other included interventions to monitor for aggression and provide feedback, but there was no evidence that these interventions were adequately implemented or documented following the incident. The failure to monitor and document as required had the potential to negatively impact the well-being of the residents involved.