Failure to Prevent and Document Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in a deficiency. On the date of the incident, one resident with severe cognitive impairment and a history of behavioral issues, including agitation and aggression, struck another resident, also with severe cognitive impairment, in the arm while both were in the dining room. The residents were immediately separated, and skin assessments were reportedly completed, though no injuries were observed. However, the facility was unable to provide documentation of the skin assessments for the resident who was struck. The investigation into the incident revealed that both residents resided in the memory care unit and were dependent on staff for most activities of daily living. The resident who struck the other had a care plan for behavioral problems, but this plan was only created after the incident, during the survey. The other resident, who was the victim, had a care plan that included interventions to prevent behavioral escalation and to avoid positioning near others who might disturb her, but there was no documentation in her medical record regarding the physical altercation. Staff interviews confirmed the event, with the registered nurse on duty recalling that the residents were in close proximity and that the aggressor was agitated at the time. The nurse assessed the victim, but neither resident expressed fear of the other. The nursing home administrator and director of nursing agreed with the documentation in the records and investigation reports but could not provide the required skin assessment documentation for the victim. The facility's failure to prevent the physical abuse and to document the required assessments contributed to the deficiency.