Failure to Protect Resident from Repeat Abuse Resulting in Harm
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from resident-to-resident abuse, resulting in actual harm. The incident began when a resident with a history of impulsive and aggressive behavior, as well as prior altercations, was involved in a physical altercation with another resident in the elevator. The first resident initiated the altercation by hitting the second resident, who then retaliated. Staff intervened and separated the residents, and both were assessed with no immediate injuries found. However, there was a delay in implementing close visual monitoring or 1:1 supervision for the resident identified as high risk for abuse, despite this being an intervention in their care plan. Following the initial altercation, the resident who was at high risk for abuse returned to their room. Later, the same day, the second resident entered the first resident's room, and another unwitnessed altercation occurred. The first resident subsequently complained of chest pain and was transferred to the emergency department, where they were diagnosed with an acute rib fracture. Documentation and interviews revealed that staff had not yet implemented the required close visual monitoring or 1:1 supervision at the time of the second incident, despite instructions to do so after the first altercation. The facility's failure to promptly implement safety measures and monitoring after the initial incident allowed for a second altercation to occur, resulting in actual physical harm to the resident. The care plan for the resident at high risk for abuse included interventions such as close monitoring, but there was no documented evidence that these were put in place in a timely manner. This lapse in protection and supervision directly contributed to the resident sustaining a serious injury.