Failure to Prevent Resident-to-Resident Physical Altercation Resulting in Injury
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from abuse and neglect, as required by regulation. On the evening of the incident, a Licensed Practical Nurse responded to a loud noise coming from a shared room and found one resident holding a wheelchair leg rest and the other resident sitting on the floor with a laceration and swelling to the left side of the face. The injured resident was subsequently transferred to the hospital, where medical records confirmed facial and periorbital soft tissue swelling and a laceration that required repair. Both residents involved had severe cognitive impairment and a history of dementia, with one having a documented behavior care plan for aggressive and wandering behaviors. Facility staff, including nursing and certified nursing assistants, were unable to explain how the resident came into possession of the wheelchair leg rest used in the altercation. Interviews revealed inconsistent practices regarding the storage of wheelchair leg rests, with some staff stating that leg rests were left on the wheelchair seats, in the room, or in the hallway. The Director of Nursing and other staff members confirmed that there was no prior history of altercations between the two residents and that the incident was considered unpredictable and unforeseeable. However, the facility did not investigate how the leg rest became accessible to the resident or implement interventions to prevent similar incidents. The facility's abuse prevention policy required ongoing assessment and monitoring for signs of abuse, but the care plan interventions in place did not prevent the incident. Staff interviews indicated a lack of clarity and consistency in the handling and storage of wheelchair components, which contributed to the resident's ability to access the leg rest. The facility's investigation concluded that there was no evidence of abuse, neglect, or mistreatment, but the survey findings documented a failure to ensure the resident's right to be free from abuse and neglect.