Failure to Prevent Resident-to-Resident Abuse Due to Lack of Supervision
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from abuse by another resident. The incident involved two residents with significant cognitive and behavioral health issues. One resident, who had a history of agitation and impulse control problems, became agitated in the dining room and physically confronted another resident who was exhibiting disruptive behaviors. The aggressor stood up from her wheelchair, placed her hands on the other resident's shoulders and neck, and during the altercation, her arm made contact with the other resident's nose, resulting in a nosebleed. Staff interviews and clinical record reviews revealed that there was no staff present in the dining room at the time of the incident, allowing the altercation to occur without immediate intervention. The incident was witnessed by a CNA through a window, who then called for assistance and separated the residents. The lack of supervision in the dining area was identified as a contributing factor, as staff were occupied with other duties such as medication administration, admissions, and communicating with family members. The facility's policies required prompt reporting and intervention in cases of abuse, but the absence of staff in the dining room allowed the situation to escalate. Both residents involved had complex medical and psychiatric histories, including cognitive impairment, behavioral symptoms, and a tendency toward agitation. The facility's failure to ensure adequate supervision and prevent resident-to-resident abuse resulted in physical harm to one resident. The incident was substantiated by staff interviews, clinical documentation, and policy review, confirming that the facility did not uphold its obligation to protect residents from abuse as outlined in its own policies.