Resident-to-Resident Physical Altercation Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from abuse when two residents with severe cognitive impairment engaged in a physical altercation. One resident, who had a history of physical behaviors directed towards others and was diagnosed with unspecified dementia, entered an empty room with another resident and closed the door. Another resident, also with severe cognitive impairment and a history of physical behaviors, became agitated when the door was closed in her face, pushed the door open, and physically attacked the first resident by grabbing her hair and pulling her out of the room. The altercation escalated, resulting in both residents hitting each other until staff intervened and separated them. The incident resulted in the first resident sustaining scratches to her left cheek and lip, as well as a developing bruise under her left eye. Documentation and witness statements confirmed that staff observed the altercation and responded by running to the scene to separate the residents. Prior to the incident, both residents were known to walk the hallways frequently, and staff were aware of their behavioral triggers and signs of agitation. However, there was no indication that either resident had previously exhibited physically aggressive behaviors towards others, and staff had not anticipated such an incident occurring between them. The deficiency was identified through observation, interviews, and record review, which revealed that the facility did not ensure residents were free from abuse by other residents. The altercation occurred in an unlocked, empty room at the end of the hallway, which both residents attempted to enter. The facility's failure to prevent the altercation and protect the resident from abuse constituted noncompliance with regulatory requirements for resident safety and freedom from abuse.