Failure to Separate Residents During Altercation
Penalty
Summary
The facility failed to separate two residents during a resident-to-resident altercation, resulting in one resident physically striking another. One of the residents involved had severe cognitive impairment, as indicated by a BIMS score of 3, and a history of delusions and impaired short-term memory. The care plan for this resident directed staff to reorient and redirect her as needed. The other resident had no cognitive impairment but had a history of anxiety, depression, and behavioral symptoms. Both residents had documented behavioral care plans that included redirection and education as interventions. On the day of the incident, dietary staff observed the cognitively impaired resident becoming verbally aggressive toward another resident over silverware. The resident then struck the other resident in the chest. Staff interviews revealed that the dietary manager did not immediately separate the residents, citing concerns about holding a coffee pot and the potential for aggression. The nurse was called to the scene, and only then were the residents separated. The resident who was struck denied injury and reported this was the first such incident. Further interviews with staff indicated that the standard response to such altercations would be to redirect and separate the residents, but this was not done promptly in this case. The facility's abuse prevention policy, provided during the investigation, commits to protecting residents from abuse, including from other residents. However, the failure to immediately separate the residents during the altercation constituted a lapse in following this policy and the residents' care plans.