Failure to Prevent Resident-to-Resident Physical Abuse Due to Inadequate Supervision
Penalty
Summary
A resident with moderate cognitive impairment and a history of dementia, coronary artery disease, heart failure, and hypertension sustained a skin tear to the right elbow after being grabbed by another resident. The incident occurred when the first resident tapped the second resident on the shoulder, prompting the second resident to grab the first resident's arm. Staff interviews confirmed the sequence of events, with a CNA observing the arm being squeezed and an LPN noting that the first resident often approached others in this manner. The resident who sustained the injury was not fearful and had limited recollection of the incident. The second resident involved had a care plan indicating frequent, unpredictable, and impulsive behaviors, including a risk of slapping or punching others. The care plan required adjusted supervision to prevent aggression, and staff were expected to keep this resident greater than arm's length from others. However, on the day of the incident, this supervision did not occur, and the resident was observed unsupervised in the hallway for an extended period. The facility's abuse prevention policy defined abuse to include hitting, slapping, scratching, and pinching, and required interventions to protect residents, which were not effectively implemented in this case.