Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with a history of aggressive behaviors physically struck another resident in the face after a dispute over a personal item. The incident was witnessed by a State Registered Nurse Aide, who observed the aggressor resident become upset and swat the other resident on the nose twice. The resident who was struck reported feeling as though her nose had been broken, though no follow-up care was recommended by the nurse practitioner at the time. The incident took place in a common area near the nurses' station, and another resident also reported being hit by the same aggressor during the same episode. The resident who committed the physical abuse had a documented history of behavioral issues, including physical and verbal aggression toward others, as well as severe cognitive impairment. Her care plan prior to the incident included interventions such as allowing space, redirecting as needed, and removing her from public areas when behaviors posed a risk for harm. Despite these interventions, the resident was able to physically harm another resident, indicating a failure to prevent resident-to-resident abuse as outlined in the facility's abuse prevention and resident rights policies. The resident who was struck was also severely cognitively impaired and had multiple medical diagnoses, including acute kidney failure and malignant neoplasm of the lung. Interviews with staff and family members confirmed the occurrence of the incident and the aggressor's history of similar behaviors. The facility's policies required the prevention, identification, and reporting of abuse, but the incident demonstrates that these measures were not sufficient to protect the resident from physical abuse by another resident.