Failure to Protect Residents from Physical Abuse and Lack of Incident Reporting
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by an altercation between two residents in the dining room. One resident, with intact cognition, reported being struck in the face by another resident after grabbing the back of the other resident's wheelchair. The altercation escalated, with both residents exchanging blows, and a CNA intervened to separate them. Both residents confirmed the incident during interviews, and a CNA and LPN also acknowledged witnessing or being informed of the physical altercation. However, there was no documentation of the incident in either resident's nurse's notes or care plans. Staff interviews revealed that the incident was not reported to facility administration or the Director of Nursing, despite staff recognizing the event as physical abuse. The facility's abuse prevention manual defines physical abuse to include hitting and slapping, and both the DON and administrator confirmed that such incidents should be reported immediately. The lack of documentation and failure to report the altercation constituted a deficiency in protecting residents from abuse.