Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a resident reported being physically struck by their roommate during a verbal altercation. The incident involved one resident propelling their wheelchair to the other side of the shared room and striking the other resident twice on the left chest and neck area. Documentation showed that both residents had care plans addressing potential for abuse and impaired cognitive function, with interventions such as monitoring behaviors and assessing needs. Despite these plans, the altercation occurred, and the incident was reported as required by facility policy. The resident who was struck had diagnoses including atrial fibrillation, hypotension, and cardiomegaly, and was cognitively intact but required assistance with daily activities. The other resident had acute kidney failure, hypotension, hyperlipidemia, and moderate cognitive impairment, with a history of impaired thought processes. The facility's policies required immediate reporting and individualized monitoring for residents at risk of altercations, but the event still took place, indicating a failure to protect the resident from abuse as required.