Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to ensure that a resident was free from abuse when an altercation occurred between two residents, resulting in one resident sustaining a scratch on his nose. Both residents involved had severe cognitive impairment and a history of dementia and cerebrovascular accidents, with one resident also experiencing hemiplegia. The incident took place when one resident entered the other's room, reportedly to retrieve personal belongings he believed were left there, as it had previously been his room. The resident occupying the room was asleep, became startled upon awakening to find someone going through his belongings, and responded by physically assaulting the other resident, including punching and overturning his wheelchair. Prior to the incident, both residents had been roommates and reportedly got along well, but one had requested a room change, which was accommodated. There was no documented history of aggression between the two residents before this event. The care plans for both residents included interventions for managing physical behaviors and aggression, such as 1:1 monitoring, psychiatric consults, and de-escalation techniques. However, at the time of the incident, these interventions did not prevent the altercation from occurring, and the staff were alerted to the situation by a vendor who witnessed the fight. Upon arrival, staff found one resident on the floor and the other actively hitting him. The staff separated the residents and assessed the injured resident, who was found to have a bleeding scratch on his nose. Interviews with staff and review of records confirmed that the residents had not previously exhibited aggressive behavior toward each other or other residents. The facility's policy required separation of residents involved in altercations and ongoing assessment, but the incident demonstrated a failure to protect the resident from abuse as required.