Failure to Prevent Resident-to-Resident Abuse During Altercation
Penalty
Summary
The facility failed to ensure that residents were protected from abuse, neglect, misappropriation of property, and exploitation, as evidenced by an incident involving two residents. One resident, who had dementia, bipolar disorder, and schizoaffective disorder with moderate cognitive impairment, was involved in a physical altercation with another resident who was cognitively intact but had a history of schizophrenia and impaired vision. The altercation began when the cognitively intact resident believed the other resident had taken her purse, leading to a verbal dispute and a physical struggle over the purse. During the incident, staff observed the two residents tugging on the purse and intervened to separate them. Despite staff intervention, the cognitively intact resident struck the other resident in the face with a closed fist. Immediate assessment by nursing staff found no pain or injury, and the incident was reported to the appropriate facility leadership. The resident who was struck had no recollection of the event, and her responsible party reported no visible injuries or concerns about her care. Interviews with staff and review of care plans indicated that the resident who initiated the physical contact had no prior history of aggression, and the resident who was struck had a known pattern of entering other residents' rooms and taking items. The facility's policy required prevention and prohibition of abuse, neglect, and exploitation, but the incident demonstrated a failure to prevent resident-to-resident abuse in this instance.