Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of Alzheimer's disease, dementia with psychotic disturbance, and anxiety disorder pushed a rolling bedside table into his roommate, who also had similar cognitive and psychiatric diagnoses. This action caused the roommate to fall to the ground and sustain a significant skin tear on his left forearm. The incident was witnessed by an LVN, who reported that there was no prior indication of aggression or conflict between the two residents, and no previous behavioral issues had been documented for either individual. Both residents were severely cognitively impaired, as indicated by their BIMS scores of 3, and were receiving psychotropic medications. The care plans for both residents noted their cognitive deficits and behavioral health diagnoses but did not document any prior behavioral problems or risk factors for resident-to-resident altercations. The incident was not preceded by any observable triggers, arguments, or changes in medical status, and staff reported that there were no signs that would have predicted such an event. The facility's policy states that residents have the right to be free from abuse, including resident-to-resident physical abuse. Despite this, the event resulted in physical harm to one resident due to the actions of another. The incident was reported and investigated, but the investigation concluded that the intent to harm was inconclusive, as the action was interpreted as an attempt to move the table rather than a deliberate act of aggression.