Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, specifically resident-to-resident abuse. During the incident, a nurse aide (NA) heard yelling and, upon investigation, observed one resident kicking another in a hallway. The resident being kicked was severely cognitively impaired, nonverbal, and dependent on staff for all activities of daily living, with a history of wandering and grabbing objects or other residents' wheelchairs to propel herself. The resident who was kicking was alert, oriented, and had a documented history of being combative and physically aggressive with staff. Multiple staff interviews confirmed that the cognitively impaired resident was attempting to back away but was slow moving and nonverbal, only occasionally singing. The NA immediately separated the residents and notified the unit manager, who assessed the resident and found no visible injuries. The unit manager and other staff noted that the resident being kicked would likely have experienced pain or fear but was unable to communicate her feelings. The aggressive resident admitted to kicking the other resident several times, stating she was defending herself because the other resident would not move away. Documentation and interviews revealed inconsistent accounts among staff regarding whether physical contact occurred, but at least one staff member witnessed repeated contact with the lower legs. The incident was reported to the social worker and nurse practitioner, both of whom were informed that the aggressive resident had a history of such behavior. The facility's failure to adequately supervise and protect the vulnerable resident from abuse by another resident constituted a deficiency in ensuring resident safety and upholding residents' rights.