Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from physical abuse by another resident. The incident took place when a resident, who was blind and had a history of schizophrenia, bipolar disorder, and nicotine dependence, became agitated after being told by a CNA that it was not time to smoke. The CNA attempted to prevent the resident from getting up due to fall risk, but did not notify the RN of the resident's agitation. Another resident, who had type 2 diabetes, blindness in one eye, and major depressive disorder, observed the situation and believed the agitated resident was going to harm the CNA. Acting on this belief, the second resident struck the first resident on the jaw, causing pain that required an x-ray to rule out a fracture. The facility's records and interviews confirmed that the agitated resident was attempting to get up from bed to smoke outside of designated hours, and the CNA intervened to prevent a fall. The second resident, witnessing the interaction, interpreted the agitated resident's behavior as threatening toward the CNA and decided to intervene physically. The staff responded to the incident after hearing a commotion, separated the residents, and later moved the aggressor to another room. The injured resident reported pain and anger following the incident, and the x-ray showed no fracture. Review of facility policies indicated that staff are expected to identify and prevent all forms of abuse, including resident-to-resident abuse, and to notify the charge nurse immediately if there are concerns about resident behavior or policy violations. The policies also require staff training in abuse prevention and management of aggressive resident behavior. In this case, the failure to notify the RN of the resident's agitation and the lack of effective intervention allowed the physical altercation to occur, resulting in harm to a resident.