Failure to Protect Resident from Resident-to-Resident Abuse
Penalty
Summary
A deficiency occurred when a resident was not protected from resident-to-resident abuse. The incident involved one resident, who was cognitively intact but had a history of traumatic brain injury and stroke, striking another resident on the forehead with his fist. The altercation happened as the first resident attempted to exit their shared room in his wheelchair but was blocked by the other resident's geri-chair. The resident who was struck had severe cognitive impairment, dementia with psychotic disturbance, and a history of physical aggression toward staff, but no prior behavioral concerns with other residents were documented. The event was directly observed by nursing staff, who immediately separated the two residents. The resident who was struck sustained a raised red area on his forehead and was later evaluated in the emergency room, where a CT scan was negative for acute injury. The resident who initiated the altercation admitted to hitting the other resident because he was blocked and felt ignored. There was no documentation of previous altercations or arguments between these two residents prior to this incident. Care plans for both residents noted their respective cognitive and behavioral histories, but there was no indication of prior issues between them. The incident was reported to the appropriate authorities, and both residents' representatives were notified. The deficiency was identified as a failure to protect a resident from abuse by another resident, as required by regulations.