Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
A deficiency occurred when one resident physically assaulted another, resulting in injury. Specifically, a resident with a diagnosis of unspecified psychosis, dementia, and muscle weakness pushed and hit another resident who had Alzheimer's disease, muscle weakness, and required assistance with personal care. The incident led to the assaulted resident sustaining two skin tears: one on the left elbow measuring 2 cm by 2 cm, and another on the right forearm measuring 1 cm by 0.5 cm. The injured resident reported the assault, and the aggressor admitted to the action when questioned. Facility staff, including the DON and ADON, acknowledged that the assault took place. The facility's abuse prevention policy, revised in November 2023, states that all residents have the right to be free from abuse, including abuse by other residents, and defines abuse as the willful infliction of injury. The events described in the report indicate that the facility failed to prevent abuse between residents, resulting in physical harm.