Failure to Protect Residents from Abuse During Altercation
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in an altercation between them in an elevator. One resident, with a history of psychosis, hallucinations, Parkinsonism, and anxiety disorder, and another resident, with diagnoses including diabetes, cerebral infarction, acute kidney failure, and opioid use, were both cognitively intact according to their BIMS scores. The incident began when one resident refused to allow another resident onto the elevator, leading to a verbal confrontation and subsequent physical altercation. Multiple accounts from those present provided conflicting descriptions of who initiated the physical contact, but it was confirmed that both residents sustained minor injuries during the event. A nurse assessed the residents after the altercation and noted that one had a bite mark on her hand, with broken skin, which required medical attention. An order for antibiotics was given to prevent infection due to the bite. The facility's policy affirms residents' rights to be free from abuse, including physical injury inflicted by non-accidental means. The incident demonstrated a failure to ensure residents were protected from abuse by others within the facility, as required by policy.