Failure to Prevent Resident-to-Resident Abuse Resulting in Injuries
Penalty
Summary
The facility failed to protect two residents from abuse when a physical altercation occurred between them. Resident 2, who had dementia with behavioral disturbances and severe cognitive impairment (BIMS score of 5), and Resident 4, who had moderate cognitive impairment (BIMS score of 10) and a diagnosis of osteomyelitis, were involved in the incident. Resident 2 sustained multiple skin tears with bleeding, while Resident 4 suffered a skin tear on her right index finger after being bitten. The altercation began when Resident 4 became upset that Resident 2 was using her wheelchair, leading Resident 4 to scratch Resident 2, and Resident 2 to bite Resident 4's finger. A registered nurse responded to a commotion in the shared room and observed Resident 4 swinging her arms at Resident 2, who was attempting to defend herself. Staff intervened and separated the residents, but not before Resident 2 had sustained significant injuries. The facility's abuse prevention policy prohibits all forms of abuse and neglect, but the incident resulted in pain and injuries to both residents, indicating a failure to ensure their safety from abuse.