Failure to Prevent and Report Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent abuse between two residents when one resident physically assaulted another following an incident involving personal belongings. Both residents involved were assessed as having no cognitive impairment according to their Brief Interview of Mental Status (BIMS) scores. The altercation began when one resident entered the other's room and was found going through personal items, which led to a confrontation where the resident whose belongings were disturbed followed the other through a shared bathroom and punched her in the face. Multiple staff interviews confirmed that this was the first physical altercation between these residents, although one resident had a known history of entering other residents' rooms and taking items. Despite the physical altercation, there was no evidence of injury to either resident, and neither required hospitalization. Staff, including RNs and CNAs, were aware of the incident and reported it to facility management, including the Administrator and DON. However, the incident was not documented in the residents' medical records at the time, and there was no initial report filed for the altercation. The police were not notified, and the event was not reported externally as required by facility policy. Interviews with staff indicated that the resident who was assaulted had previously expressed frustration over repeated thefts and felt compelled to act due to perceived inaction by the facility. The facility's abuse, neglect, and exploitation policy defines abuse to include resident-to-resident altercations such as hitting and punching. Staff acknowledged that the resident who entered others' rooms had a history of such behavior and that interventions such as redirection and education had been attempted. However, the lack of timely documentation, failure to report the incident as abuse, and absence of an initial report represent failures in the facility's processes to protect residents from abuse and to follow established protocols for reporting and investigating such incidents.