Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by each other, resulting in a substantiated incident of resident-to-resident physical aggression. Both residents involved were severely cognitively impaired, with documented histories of behavioral disturbances, including physical aggression and verbal outbursts. On the date of the incident, a certified nurse aide (CNA) witnessed the two residents facing each other and making hand-to-hand, swatting gestures that resulted in physical contact. The CNA immediately intervened by separating the residents and notifying the nurse on duty. Although no injuries were initially reported, a subsequent assessment revealed that one resident had sustained a skin tear on the back of her left hand. Record reviews indicated that both residents had care plans addressing their behavioral issues, including interventions such as providing activities of interest, removing them from high-traffic areas, and ensuring they were kept apart from residents with whom they had previous altercations. Despite these interventions being documented, the incident occurred in a common area, suggesting that the measures in place were not effectively implemented at the time of the altercation. Staff interviews confirmed that both residents were known to exhibit aggressive behaviors and required close monitoring to prevent such incidents. Observations and staff accounts further revealed that both residents were prone to agitation and could be triggered by loud environments or interactions with each other. Staff described using redirection techniques and attempting to keep the residents separated, but the altercation still occurred. The facility's policy required protections against abuse, including resident-to-resident altercations, but the failure to prevent this incident constituted a deficiency in safeguarding residents from abuse.