Failure to Prevent Resident-to-Resident Physical Abuse Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when the facility failed to follow its policy to protect a resident from physical abuse by another resident. One resident, who had a history of behavioral issues including aggression and manipulative behavior, struck another resident in the face with a glass bottle, resulting in an open wound above the left eyebrow. The incident took place near the dining room, and staff were not positioned to adequately supervise all residents in the area, as confirmed by their own statements that they could not see all residents from where they were seated. The resident who was struck had significant medical conditions, including hemiplegia and severe cognitive impairment, and reported feeling scared and experiencing headaches after the incident. Multiple staff members, including CNAs and LPNs, acknowledged that residents are not supposed to hit each other and that such altercations are considered abuse. The staff also admitted to being distracted or not optimally positioned for supervision at the time of the incident, with some using their phones for charting or personal use, which further limited their ability to monitor resident interactions and prevent altercations. Documentation and interviews revealed that the facility's policies on supervision and abuse prevention were not effectively implemented. The incident was reported to the police, and the aggressor was sent to the hospital for psychiatric evaluation. However, the failure to provide adequate supervision and to prevent the altercation directly led to the physical abuse and injury of a resident, as well as emotional distress.