Failure to Prevent and Document Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from physical abuse when a resident-to-resident altercation occurred in a common area. One resident, who was cognitively intact and had a history of psychosocial risk, was struck in the neck by another resident with a history of physical aggression related to dementia. Staff immediately separated the residents and assessed for injuries, with none noted. However, there was no documentation in the nurse's notes regarding the incident, and the care plan interventions for both residents did not reflect any new measures to prevent further altercations following the event. Interviews revealed that the current administrator and director of nursing were not aware of the details of the incident, and the director of nursing had not been informed of any new interventions implemented after the altercation. Additionally, a family member of the affected resident reported not being informed of the outcome and expressed concern about the lack of increased monitoring. The facility's abuse policy requires procedures to prevent abuse, but the lack of documentation and follow-up interventions indicated a failure to fully address the incident.