Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent an incident of resident-to-resident physical abuse when one resident struck another on the back of the head. Resident 1, who had diagnoses including end stage renal disease and vascular dementia but was assessed as having intact cognitive skills for daily decision making, hit Resident 2 after Resident 2 spilled hot chocolate on her. Resident 2, who had peripheral vascular disease, dementia with moderately impaired cognitive skills, anxiety disorder, and depression, reported feeling distressed as a result of the altercation. Resident 1 admitted to hitting Resident 2 and stated it was in response to being called names. The incident was reported by Resident 2 to staff, and both residents confirmed the details during interviews. The Director of Nursing acknowledged recent changes in facility leadership and management, and emphasized the importance of improved resident assessment and care planning to prevent such altercations. A review of the facility's abuse prevention policy indicated that the facility is responsible for identifying, correcting, and intervening in situations where abuse is more likely to occur.