Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to prevent abuse for one of three residents reviewed for abuse, resulting in a resident being cut on the face with a butter knife and falling from a wheelchair, which required hospital evaluation and treatment. The incident occurred in the dining room, where two residents were seated at separate tables. One resident, who had diagnoses including anxiety disorder, dementia, and chronic atrial fibrillation, stood up, took a butter knife, and stabbed another resident in the cheek. The altercation lasted approximately 35 to 40 seconds, during which the injured resident slid from the wheelchair and landed on the floor. The resident who was attacked had a history of sepsis, dementia, contractures, and chronic pain syndrome, and was documented as moderately cognitively impaired. The care plan for this resident noted behavioral issues such as attention-seeking and fixation due to anxiety and depressive disorders. The attacking resident had no cognitive deficits documented but was noted to have an alteration in neurological status requiring cueing and reorientation. Staff in the vicinity responded after hearing the injured resident scream, and immediate assessment and first aid were provided. The incident was captured on video surveillance, confirming the sequence of events. Staff interviews indicated that the attacking resident had not previously exhibited such behavior and that staff were present in the dining room but did not prevent the incident. The facility's abuse policy affirms residents' rights to be free from abuse and outlines the facility's responsibility to prevent such occurrences. Despite these policies, the incident occurred, resulting in physical harm to a resident and the need for hospital transfer.