Failure to Protect Resident from Physical Abuse During Resident-to-Resident Altercation
Penalty
Summary
A deficiency occurred when a resident with a history of mild memory impairment and multiple medical conditions, including chronic kidney disease and thrombotic disorders, sustained a burn injury after another resident threw a cup of hot coffee at him. The incident followed a verbal altercation between the two residents, during which the aggressor, who had a documented history of verbally aggressive behavior and schizotypal disorder, became upset when the injured resident entered his room and did not leave after being asked. The aggressor then threw a coffee cup, resulting in hot coffee splashing onto the other resident's right arm and hand, causing redness and a bruise. Medical records and staff interviews confirmed the sequence of events, with the injured resident reporting the incident to a treatment nurse, who observed scalding on the right arm. The aggressor admitted to throwing the coffee cup after repeated requests for the other resident to leave his room were ignored. Documentation in both residents' care plans and progress notes described the altercation and the resulting injury, with the aggressor's care plan noting a history of behaviors that could increase the risk of conflict with peers. The facility's policy on abuse prohibition defines abuse as the willful infliction of injury, and staff interviews, including with the DON, confirmed that the injury was the result of a willful act. The failure to prevent this resident-to-resident altercation resulted in physical harm and demonstrated a lapse in protecting residents from abuse as required by facility policy.