Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent abuse when a physical altercation occurred between two residents. One resident, who had a history of being easily annoyed, agitated, and verbally aggressive, was involved in an incident where he struck another resident after their wheelchairs accidentally bumped in the dining room. The resident who was struck had a diagnosis of dementia and no documented behavioral issues or history of aggression. The incident was witnessed by a CNA, who observed the altercation and immediately separated the residents. Documentation revealed that neither resident sustained injuries, and there was no evidence of prior or subsequent physical aggression from the resident who initiated the altercation. However, the care plan for the resident with dementia did not address her risk for abuse, and there was no documentation in the nurse progress notes of the altercation on the day it occurred. The facility's abuse prevention policy affirms residents' rights to be free from abuse, but the lack of risk assessment and care planning for the resident with dementia contributed to the deficiency. Interviews and written statements confirmed the sequence of events, with staff and the resident involved providing consistent accounts of the incident. The facility's records and follow-up documentation did not fully reflect the details of the altercation as observed by the CNA, and the care plan for the resident at risk did not include measures to prevent abuse. This failure to identify and address the risk for abuse resulted in the facility not protecting all residents from abuse as required.