Failure to Prevent Resident-to-Resident Physical Abuse Due to Lack of Supervision
Penalty
Summary
The facility failed to protect two residents from physical abuse when a verbal altercation in the smoking patio escalated into a physical confrontation. One resident, who had moderately impaired thought processes and required moderate assistance with activities of daily living, was grabbed by the neck and choked by another resident. This resulted in the victim falling to the ground, experiencing pain in the right knee, and feeling shocked and scared. The incident was witnessed by another resident, who reported that staff were not present in the smoking patio at the time of the altercation and that no staff could be found at the nurses' station immediately after the event. The resident who was attacked had a history of osteoarthritis and hypertension and was assessed as having the capacity to understand and make decisions. After the incident, the resident reported pain and emotional distress, and a post-fall evaluation confirmed mild pain in the right knee. The aggressor, who also had moderately impaired thought processes and required supervision for transfers and ambulation, was reported to have left the area immediately after the incident. Staff interviews confirmed that the event was not witnessed by staff, and the initial response was triggered by a certified nursing assistant who heard a noise and found the victim on the floor. Both the Administrator and the DON acknowledged that staff should have been present in the smoking patio to ensure resident safety, as required by the facility's abuse prevention policy. The policy specifically states that residents have the right to be free from abuse, including abuse by other residents, and that the administration is responsible for protecting residents from such incidents. The lack of staff supervision in the smoking patio directly contributed to the occurrence of physical abuse between residents.