Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to follow its abuse prevention policy and did not prevent a resident-to-resident physical altercation involving two residents. One resident, with a diagnosis of schizoaffective disorder and a history of poor impulse control, was identified in the care plan as having the potential to be physically or verbally aggressive, with interventions specified to de-escalate agitation and guide the resident away from sources of distress. The other resident, diagnosed with schizophrenia, was care planned for risk of abuse with interventions to observe the resident when in the company of peers. Despite these care plans, an incident occurred in the dining room where one resident backed into another with a wheelchair, leading to a physical altercation in which both residents struck each other, resulting in minor scratches to one resident's face. Staff were present during the incident and intervened immediately, but the altercation had already escalated to physical contact. Interviews and statements from the residents and staff confirmed that the incident was intentional and not accidental. The facility's abuse prevention policy requires identification of residents at risk for abuse and implementation of interventions to reduce the chances of abuse, as well as ongoing monitoring and updating of care plans. However, the failure to effectively implement these interventions and supervise the residents led to the occurrence of physical abuse between residents.