Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, as evidenced by an incident involving two residents. One resident, with a history of dementia and being intrusive into others' space, approached another resident who was cleaning a fish tank and began yelling. The situation escalated, resulting in the first resident striking the second resident across the face, causing three open scratches that drew blood. The care plan for the resident with dementia included interventions such as redirection and removal from the environment as needed, as well as observation and reporting of behaviors that could pose danger to self or others. At the time of the incident, two nurses and two CNAs were present and witnessed the altercation. The facility's policy stated that each resident has the right to be free from verbal, sexual, physical, and mental abuse. Despite the presence of staff and existing care plan interventions, the incident occurred, indicating a failure to implement measures to prevent resident-to-resident abuse as outlined in the facility's policy.