Failure to Prevent Resident-to-Resident Altercation and Maintain Ordered Safety Interventions
Penalty
Summary
The facility failed to protect residents from abuse and neglect, specifically by not preventing a resident-to-resident altercation that resulted in injury, and by not ensuring that a physician-ordered stop sign was in place at a resident's doorway. Two residents with cognitive impairments were involved in an incident where one resident entered another's room, leading to a physical altercation. The resident who entered the room sustained injuries including a cut to the nose and upper lip, and the loss of a tooth. Both residents were unable to provide reliable accounts of the incident due to their cognitive status. Medical record reviews showed that one resident had diagnoses of Alzheimer's disease, psychosis, and mood disorder, with a moderately impaired cognition, and was receiving daily antidepressants and opioid medication. The other resident had Alzheimer's disease, dementia, and heart failure, with severely impaired cognition and a history of wandering and entering other residents' rooms. The care plan for the first resident included a stop sign at the doorway to provide privacy and prevent such incidents, and staff were ordered to ensure the stop sign was in place. However, observations on multiple dates confirmed that the stop sign was not present as ordered, and staff interviews revealed it was often removed by the resident and their roommate. The facility's self-reported incident investigation was inconclusive due to lack of witnesses and the cognitive deficits of both residents, making it impossible to verify the exact sequence of events. Documentation confirmed that the required stop sign was not in place at the time of the incident, and the facility's policy defined abuse as the willful infliction of injury or unreasonable confinement. The failure to maintain the ordered intervention and prevent the altercation constituted non-compliance with regulations protecting residents from abuse and neglect.