Failure to Prevent Resident-to-Resident Physical Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure an environment free from physical abuse for two of six sampled residents. In the first incident, one resident with diagnoses including paranoid schizophrenia and major depressive disorder punched another resident in the dining room while unsupervised. The aggressor claimed the other resident repeatedly asked for money, which led to the altercation. The victim denied any prior interaction and reported feeling frustrated and upset after being punched. Staff were not present inside the dining room at the time, as they were occupied with sanitizing residents' hands at the doorway, which left the residents unsupervised during the incident. In the second incident, another resident was hit on the left side of the face by a peer while attempting to move out of the way near a doorway. Both residents involved had psychiatric diagnoses, and one had a history of inattentive or disorganized thinking. The aggressor reported being provoked by cursing and being blocked in the doorway, leading to a physical altercation. A CNA witnessed the event, noting that both residents tried to get past each other before the aggressor struck the other resident. The victim experienced mild pain and was administered Tylenol for relief. The facility's policy and procedure on physical assault requires immediate reporting of all forms of abuse, including resident-to-resident assaults, and emphasizes the need to provide a safe and secure environment. However, in both incidents, lapses in supervision and monitoring contributed to the occurrence of physical abuse between residents. Staff interviews confirmed that the absence of direct supervision in common areas, such as the dining room, may have allowed these altercations to occur.