Failure to Protect Residents from Abuse During Resident-to-Resident Altercations
Penalty
Summary
The facility failed to protect four residents from verbal and physical abuse during two separate resident-to-resident altercations. In the first incident, one resident with a history of stroke, dementia, and alcohol abuse returned from a leave of absence visibly intoxicated and became agitated when staff attempted to take his medications. This resident and another resident, who has paraplegia and a history of nerve pain, engaged in a physical altercation in the lobby. Both residents sustained injuries, including a swollen eye, laceration, and redness on the chest and face. Staff interviews revealed that both residents had prior histories of aggressive or inappropriate behaviors, and the care plans for these residents were not updated following the incident. There was no documentation of education or counseling provided to either resident regarding their aggressive behaviors after the altercation. In the second incident, two roommates, both with significant cognitive impairments and complex psychiatric and medical histories, were involved in a physical and verbal altercation in their shared room. One resident, who was severely cognitively impaired and on hospice, was struck multiple times with a shoehorn by his roommate after a verbal exchange that included racial slurs and threats. The injured resident sustained a scalp laceration, a fractured right shoulder, and a fractured right humerus, requiring hospital treatment. Staff interviews and documentation indicated that the residents had ongoing interpersonal issues, but there was no evidence of proactive intervention or reassessment of their compatibility as roommates prior to the incident. The facility lacked a formal policy for roommate placement and relied on informal assessments and staff familiarity with residents. There was no evidence that the interdisciplinary team reviewed or revised care plans or interventions following these altercations, nor was there documentation of timely or adequate staff response to escalating behaviors. The incidents resulted in significant injuries, emergency room visits, and ongoing feelings of vulnerability and fear among the residents involved.