Failure to Prevent Resident-to-Resident Physical Abuse in Dayroom
Penalty
Summary
The facility failed to protect residents' rights to be free from physical abuse, as evidenced by an altercation between two residents with severe cognitive impairment. One resident with dementia, bipolar disorder, and other comorbidities became agitated over a seating arrangement with another resident diagnosed with Alzheimer's disease, Parkinson's disease, and bipolar disorder. The situation escalated into a verbal and physical altercation in the dayroom, where only one CNA was present with twelve residents at the time. The altercation involved pushing, kicking, and grabbing, resulting in both residents sustaining skin tears and contusions on their right hands. Staff interviews and video footage confirmed that the altercation lasted approximately one minute before additional staff arrived to intervene. The CNA present attempted to separate the residents but was not strong enough to do so alone and sustained scratches in the process. The incident was witnessed by other staff who arrived after the altercation had escalated, and both residents were noted to be upset and verbally aggressive following the event. The care plans for both residents were updated to reflect the psychosocial risk related to resident-to-resident altercations after the incident. A review of facility policies revealed that residents have the right to be free from abuse, including abuse by other residents, and that the facility is committed to preventing such incidents. Despite these policies, the staffing level in the dayroom at the time of the incident was insufficient to prevent or promptly intervene in the altercation, resulting in physical harm to both residents and injury to a staff member.