Failure to Protect Resident from Physical Abuse Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident was not protected from physical abuse by another resident. The incident involved a male resident with paraplegia, major depressive disorder, and other significant medical conditions, who was struck in the face by another male resident with schizoaffective disorder and dementia. The altercation began as a verbal dispute in the smoking room and escalated to physical violence in the hallway outside the smoking room. The injured resident sustained a laceration and bruise to the lip, which was observed by the surveyor the following day. At the time of the incident, the smoking room was supposed to be monitored by staff, but interviews revealed inconsistent supervision. The staff member assigned to monitor the smoking room was responding to a call light in another room when the altercation occurred, leaving the area unsupervised. Other staff members confirmed that the smoking room was not always consistently monitored, and one resident present during the incident stated that no staff were monitoring the room at the time. The lack of supervision allowed the situation to escalate without immediate intervention. Documentation and interviews indicated that the facility did not have an abuse care plan in place for the injured resident prior to the incident. The facility's abuse prevention policy affirms the right of residents to be free from abuse and outlines the importance of a secure environment, but the absence of consistent monitoring and a specific care plan contributed to the failure to prevent the physical abuse. The incident was reported to the police, and both residents were separated after the event, but these actions occurred after the deficiency had already taken place.