Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent an incident of physical abuse between two residents, both of whom were severely cognitively impaired and had no prior history of aggressive behavior. The event occurred in the early morning hours when a CNA, after providing care to another resident, observed the two residents engaged in a physical altercation at the end of a hallway. The CNA witnessed one resident striking the other in the face and immediately called for assistance. Two LPNs responded, separated the residents, and performed assessments. The resident who was struck sustained a small laceration and redness to the left eye/eyebrow area, as well as a bruise to the left hand and reported forearm pain. The other resident did not have any injuries and denied pain. Both residents were unable to provide coherent accounts of the incident due to their cognitive impairments. Staff interviews confirmed that neither resident had a documented history of aggression, although one was noted to become agitated with care. The incident was witnessed by staff, and the facility's own investigation substantiated that physical abuse had occurred. At the time of the incident, the CNA was occupied in another room, and the LPNs were preparing medications in the medication room, leaving the residents unsupervised in the hallway. The facility's abuse prevention policy prohibits physical abuse, including hitting and striking, and affirms the right of residents to be free from such harm. Despite these policies, the lack of supervision allowed the altercation to occur, resulting in injury to one resident.