Failure to Prevent Resident-to-Resident Physical Abuse in Dining Room
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by an incident involving two residents in the dining room. One resident, with a history of hemiplegia, hemiparesis, anxiety, and delusional disorder, approached another resident, who had diagnoses including traumatic subdural hemorrhage, drug-induced Parkinson's, and anxiety disorder. Both residents were alert and able to verbalize their needs. During the incident, one resident began yelling, prompting the other to approach and physically strike him multiple times. The second resident retaliated, and the altercation continued until staff intervened. Video surveillance confirmed that the physical altercation involved multiple strikes and that staff were unable to immediately stop the incident. Staff interviews revealed that the nurse on duty was attending to another resident when the altercation began and responded by yelling and attempting to intervene. Additional staff, including human resources and kitchen staff, arrived after hearing the commotion and assisted in separating the residents. Both residents and staff acknowledged that the physical contact constituted abuse. The facility's policy prohibits resident abuse, including physical abuse such as hitting, slapping, and other forms of corporal punishment. Despite these policies, the incident occurred, and staff were not able to prevent or immediately stop the abuse between the residents.