Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with a history of verbal and physical aggression struck another resident in the face, resulting in scratches and pain. The incident took place in a hallway, where staff responded after hearing yelling. Certified Nurse Aides had already separated the residents by the time the nurse arrived. The aggressor had a care plan in place for behavioral issues, which included monitoring and documenting behaviors and attempting to determine underlying causes, but the resident was still able to physically assault another resident. The resident who was struck had no documented behavioral issues and required partial to moderate assistance with activities of daily living. After the altercation, the resident was found to have two scratches on the face, one above the lip and one near the left eye, and reported pain. The resident’s glasses were also bent during the incident. The nurse cleaned the wounds and administered pain medication as needed. The resident expressed not wanting to be hit and reported a prior history of problems with the aggressor, though no previous physical altercations had occurred. Staff interviews revealed that the aggressor was known to be verbally aggressive and could be difficult during care and medication administration. Staff had been inserviced on the facility’s abuse and neglect policy, and the care plan for the aggressive resident included interventions for monitoring and redirection. Despite these measures, the physical altercation occurred, indicating a failure to protect residents from abuse as required by facility policy.