Failure to Protect Resident from Psychosocial Abuse During Resident-to-Resident Altercation
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from psychosocial abuse. The incident involved a resident who engaged in aggressive and threatening behavior, including yelling explicit and derogatory language, making threats of physical harm, and attempting to enter another resident's room. The aggressive resident was observed slinging a wet floor sign and throwing it at a door, which struck an LPN, and subsequently throwing a chair. The targeted resident remained in their room with the door shut during the altercation and did not provoke the incident. Following the event, the targeted resident expressed significant fear and distress, reporting to staff that the threats and yelling caused chest pain and shaking. The resident voiced concerns about their safety, particularly at night, and indicated that the only time they experienced such symptoms was during the incident. The aggressive resident was sent to the emergency room for evaluation and did not return to the facility. The facility's policy required immediate intervention to halt abusive behaviors and ensure resident safety, including removing the abusive resident and providing supervision. However, the report indicates that the facility did not fully implement all aspects of its policy during the incident. There were no additional resident or staff interviews included in the initial investigation, and the targeted resident's psychosocial distress was not immediately addressed beyond reassurance after the aggressive resident was removed.