Failure to Prevent Resident-to-Resident Abuse Resulting in Harm
Penalty
Summary
A deficiency occurred when a resident with moderately impaired cognition and a history of wandering and physical behavioral symptoms entered another resident's room and struck that resident, who was cognitively and physically impaired, in the head. The incident took place in the early morning hours, and staff responded after hearing yelling. The resident's wife, who was present, reported that the aggressor had hit her and attempted to hit her husband. The injured resident was found with a red area on the left side of his forehead, and staff documented the event in the electronic health record and witness statements. Prior to the incident, the resident who initiated the altercation had documented behaviors including wandering, rejection of care, and physical symptoms directed toward others. The care plan for this resident included interventions such as staff developing rapport, anticipating needs, and monitoring for signs of discomfort or distress. Despite these interventions, the resident was able to enter another resident's room multiple times, as reported by the injured resident's wife, who had previously redirected the resident out of the room on several occasions without incident. On the day of the event, the resident's wife was unable to prevent the physical altercation, resulting in harm to both herself and her husband. The facility's investigation included multiple staff and administrative witness statements, some of which noted visible injuries to the resident, while others did not observe marks or bruising. Staff interviews confirmed that the protocol for suspected resident-to-resident abuse was to separate the residents, ensure safety, notify the nurse, and document the incident. However, the administrative staff acknowledged that the incident was not reported to the State Agency as required by facility policy. The deficiency was cited at a scope and severity of G, indicating actual harm and fear or anxiety for the resident involved.