Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect two residents from abuse and neglect when a resident-to-resident altercation occurred. One resident with significant cognitive impairment and a history of wandering and agitation entered another resident's room. The second resident, who also had cognitive impairment and a history of verbal and physical behavioral symptoms, became upset and physically assaulted the first resident, resulting in a head injury and scalp laceration that required hospital treatment. Prior to the incident, staff were aware of both residents' behavioral histories, including the first resident's increased wandering and aggression, and the second resident's verbal threats toward the first resident if he entered the room again. Documentation and interviews revealed that staff had been notified of the risk, as a CNA had informed an LVN that the second resident had threatened to harm the first resident if he returned to the room. Despite this warning, the first resident was able to re-enter the second resident's room, leading to the altercation. The facility's records showed that the first resident had a care plan addressing wandering and behavioral risks, and the second resident had a care plan for behavioral symptoms and risk of aggression. However, interventions to prevent resident-to-resident altercations were not effectively implemented, and staff did not prevent the incident despite being aware of the escalating risk. The incident was witnessed by another resident, who confirmed that the second resident punched the first resident in the face, causing him to fall and sustain injuries. Staff responded after the altercation had already occurred, and the first resident was found on the floor with bleeding and facial discoloration. The facility's investigation did not include all relevant witness statements or documentation, and the administrator did not initially recognize a system failure, despite staff being aware of the risk and the incident resulting in serious injury.