Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from abuse when one resident pushed another, resulting in a fall and injury. According to interviews and record reviews, two cognitively intact residents became involved in a verbal altercation over a personal item (a grabber). One resident accused the other of theft, leading to a confrontation in which the accused resident attempted to pass by with a walker. The accusing resident admitted to pushing the other, causing him to fall backward and strike his head and right elbow on the floor. Both residents confirmed the sequence of events during interviews, and the incident was corroborated by the facility's investigation report and staff interviews. The facility's policy prohibits abuse, mistreatment, and neglect, defining abuse as the willful infliction of injury resulting in physical harm or pain. Despite this policy, the incident occurred, and the injured resident sustained physical harm as a result of the push. Both residents were assessed as cognitively intact with no behavioral symptoms or delirium at the time of the incident, according to their Minimum Data Set assessments.