Failure to Prevent and Report Resident-to-Resident Abuse
Penalty
Summary
A resident with a history of major depression, anxiety, chronic pain, paraplegia, and other medical conditions sustained a skin tear to her left forearm after another resident, who is severely cognitively impaired with Alzheimer's disease and known for wandering and exhibiting physical and verbal behaviors, entered her room. The incident occurred when the cognitively impaired resident was asked to leave the room and instead grabbed and held the resident's arm, causing a skin tear that required cleansing and steri-strips. The injured resident reported significant pain and fear from the incident and expressed ongoing concern about encountering the other resident in the hallway. Staff interviews revealed that the cognitively impaired resident frequently enters other residents' rooms and sometimes lies in empty beds. Despite this known behavior, the facility's administrative staff, including the Administrator, Regional Administrator, and Interim DON, were not aware of the altercation at the time it occurred. There was a lack of immediate reporting and investigation, and the incident was not initially recognized as a resident-to-resident altercation by some staff. The facility's policy requires that such altercations be reviewed as potential abuse situations, but this protocol was not followed in this case.