Failure to Prevent and Address Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent physical abuse between residents, as evidenced by an altercation involving two residents with cognitive capacity for decision-making. One resident, with diagnoses including nontraumatic subarachnoid hemorrhage, malnutrition, chronic bronchitis, depression, heart failure, pleurisy, anxiety, and spinal stenosis, was noted to be independent in most activities of daily living and cognitively intact. The other resident involved had diagnoses of type 2 diabetes, morbid obesity, chronic respiratory failure, depression, anemia, hyperparathyroidism, and chronic kidney disease, and required minimal assistance for most activities. Both residents engaged in a physical altercation after a verbal dispute regarding room privacy, resulting in each striking the other, though no injuries were reported. The incident was witnessed by staff, who intervened immediately to separate the residents. However, the facility failed to update the care plans for both residents to address the altercation that occurred. The care plan for one resident referenced a previous altercation but did not include the most recent event, and the progress notes also lacked documentation of the incident. Similarly, the other resident's care plan did not reflect the altercation, despite her being identified as at risk for abuse and neglect due to her medical conditions. Interviews with staff and the residents confirmed the sequence of events, with both residents acknowledging their involvement in the altercation and the reasons behind it. The facility's policy affirms the right of residents to be free from abuse and outlines the definition of abuse, including willful infliction of injury or pain. Despite this policy, the lack of timely and appropriate care plan updates and documentation following the incident demonstrates a failure to ensure residents are protected from all forms of abuse, as required.