Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident's right to be free from abuse was not protected, resulting in a resident-to-resident altercation. One resident, with a history of bipolar disorder and bilateral below-the-knee amputation, engaged in a physical altercation with her roommate, who had a history of cerebral vascular accident and was on a blood thinner for atrial fibrillation. The incident began as an argument over the room's privacy curtain, escalating when both residents attempted to control the curtain using a reacher. The resident with bipolar disorder scratched and hit her roommate, causing multiple bruises, abrasions, and a hematoma on the roommate's left hand and arm, which later required hospital evaluation and treatment for a suspected fracture. At the time of the incident, neither resident had a care plan addressing behavioral disturbances, and both were assessed as cognitively intact with no prior behavioral symptoms directed toward others. The altercation was witnessed by a nurse aide who heard yelling and attempted to intervene, but both residents were initially unwilling to let go of the curtain. The nurse aide called for additional staff, and the residents were separated. The injured resident was found with significant bruising, scratches, and bleeding, and was subsequently transferred to the hospital for further evaluation and treatment. Interviews with staff and the residents confirmed that the altercation was related to a disagreement over the privacy curtain, and that there had been no prior incidents or complaints between the two. The resident who initiated the physical contact had previously been involved in a minor altercation with another resident but had no documented behavioral care plan. The lack of a behavioral care plan and the absence of interventions to address potential roommate incompatibility contributed to the failure to prevent the abuse.