Failure to Prevent Resident-to-Resident Abuse During Meal Service
Penalty
Summary
The facility failed to protect residents from abuse, specifically resident-to-resident abuse, as evidenced by an incident involving two residents with severe cognitive impairment and behavioral disturbances. One resident, who had a history of aggressive and combative behavior, approached another resident in the dining room and attempted to take food from their plate. In response, the second resident physically grabbed and scratched the first resident's right breast, resulting in three scratches of varying lengths. Both residents were known to have significant cognitive deficits and behavioral symptoms, including wandering and aggression. Staff interviews and documentation revealed that staff were present in the dining room but were not directly observing the altercation when it occurred. One LPN was assisting another resident and had her back to the incident, only becoming aware of the situation after hearing the commotion. A CNA intervened to separate the residents. Video footage confirmed the sequence of events, showing the first resident approaching and the second resident reacting physically. Staff acknowledged that the second resident had a history of aggressive behavior toward others, particularly when her personal space was invaded, and that interventions such as redirection had been previously implemented. The facility's abuse prevention policy defined abuse as the willful infliction of injury or harm, regardless of the mental or physical condition of the residents involved. Staff interviews indicated some uncertainty about whether the incident constituted abuse due to the cognitive status of both residents, but ultimately, the incident was treated as an abuse allegation and reported according to policy. The deficiency was identified due to the facility's failure to prevent the resident-to-resident altercation that resulted in physical harm.