Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse involving two separate incidents among four residents. In the first incident, a male resident with a history of traumatic subdural hemorrhage, bipolar disorder, anxiety disorder, heart failure, osteoarthritis, and chronic kidney disease, and with moderately impaired cognition, was involved in an altercation in the dining room with another male resident diagnosed with major depressive disorder, anxiety disorder, insomnia, paranoid schizophrenia, and unspecified psychosis. The cognitively intact resident, who was on a fluid restriction, became agitated over not receiving additional coffee, exhibited delusional behavior, and after a verbal exchange, pushed the other resident, causing him to fall and complain of hip pain. Staff attempted to intervene but were unable to prevent the physical contact. The incident was witnessed by staff, and both residents were assessed for injuries. In the second incident, a female resident with Alzheimer's disease, major depressive disorder, schizophrenia, generalized anxiety, and pica, who exhibited wandering behavior and memory problems, was pushed in the chest by a male resident with schizoaffective disorder, vascular dementia, and anxiety. The male resident, who was cognitively intact and ambulatory, encountered the female resident in a hallway he considered to be for males only. After a verbal exchange, he pushed her in the chest to get her to leave the area. This event was witnessed by a housekeeper, and staff immediately separated the residents and assessed them for injuries. The male resident later stated he had a urinary tract infection at the time, which may have affected his behavior. In both cases, the facility's staff were present and attempted to intervene, but were unable to prevent the physical altercations. The residents involved had documented histories of cognitive impairment, psychiatric diagnoses, and behavioral issues, which contributed to the incidents. The facility's care plans for these residents included interventions for behavioral management and supervision, but these measures were not sufficient to prevent the physical abuse from occurring.