Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident, as required by its Abuse Prevention and Reporting policy. One resident with a history of muscle weakness, diabetes, neuropathy, and bilateral lower limb amputations with prosthetics reported being kicked by another resident in the hallway. In response, the first resident retaliated by kicking the other resident back using her prosthetic limbs. The incident was documented in the care plans and nurse progress notes, with both residents confirming the altercation. The resident who retaliated stated a personal history of past abuse and expressed a determination to defend herself against any perceived aggression. A Licensed Practical Nurse (LPN) confirmed that a Certified Nurse Aide reported the incident, and the resident who was kicked in the legs was found to have bruising on her bilateral lower extremities. The Director of Nursing (DON) verified that the facility submitted a final incident report detailing the sequence of events, including the use of prosthetics in the altercation. The facility's failure to prevent this physical altercation between residents constitutes a deficiency in protecting residents from abuse as outlined in their policy.