Failure to Prevent Resident-to-Resident Abuse in Facility Hallway
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from physical and verbal abuse by another resident. The incident involved a resident with severe cognitive impairment and behavioral issues, who was observed yelling profanities and swinging her hands at another resident in the hallway. Multiple staff interviews confirmed that the resident with cognitive impairment had a history of aggressive behaviors, including yelling and refusing medication, and that she had recently exhibited increased confusion and agitation. The other resident involved was cognitively intact and reported being called a profanity and hit in the mouth, though she stated the hit was not hard and that the incident was captured on video, which showed hand-waving and swinging but did not clearly show a hit. Staff members, including CNAs, activity staff, and nurses, were aware of the behavioral issues of the resident with cognitive impairment and noted that both residents had a history of arguing. The incident was reported immediately by a nurse, and the administrator and DON reviewed the situation. The video footage did not provide a clear view of physical contact, but staff acknowledged the verbal abuse and the intimidating behavior displayed in the hallway. The resident who was the target of the abuse expressed embarrassment and frustration but denied being afraid. The facility's abuse prevention policy, revised shortly before the incident, outlines the responsibility to prevent all forms of abuse, including verbal and physical, and assigns the administrator as the abuse prevention coordinator. Despite these policies, the facility did not prevent the incident of verbal and possible physical abuse, as evidenced by the resident's report, staff observations, and the partial video evidence. The failure to prevent this interaction resulted in a deficiency related to resident-to-resident abuse and the facility's obligation to maintain a safe environment.