Failure to Prevent Resident-to-Resident Physical Altercation
Penalty
Summary
The facility failed to provide adequate supervision to prevent abuse between two residents who were involved in a physical altercation in a hallway near the nurses' station. One resident, who had severe cognitive impairment and a history of physical aggression, was observed in her wheelchair when she bumped into another resident's wheelchair and initiated physical contact by hitting the other resident on the forearm. The second resident, who had moderate cognitive impairment and a history of hemiplegia and hemiparesis, responded by hitting back. Both residents exchanged blows to each other's arms before being separated by staff. Documentation and interviews revealed that the first resident was unable to recall the incident due to her cognitive status, while the second resident stated he retaliated because he was struck first and felt justified in doing so. Staff interviews confirmed that the first resident had a pattern of aggressive behavior, including attempts to hit other residents and staff, and that the second resident had not previously exhibited physical aggression toward others. The incident was witnessed by staff, including the DON and a licensed nurse, who intervened to separate the residents after the altercation had already occurred. The facility's policies require staff to monitor residents for aggressive or inappropriate behavior and to protect residents from abuse, including resident-to-resident altercations. However, the lack of effective supervision and monitoring allowed the altercation to occur, resulting in both residents being exposed to potential physical injury and emotional distress. The incident was documented in progress notes and discussed in interviews with staff and the residents involved.