Failure to Prevent Resident-to-Resident Physical Abuse in Smoking Area
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident in the smoking patio area. During the incident, a verbal altercation escalated when one resident made inappropriate comments and moved his electric wheelchair toward the other, who responded by flicking a lit cigarette, spitting, grabbing the resident's arm, digging fingernails into the skin, and striking the resident in the face, causing his glasses to fall. There were no staff members present during the altercation, and another resident had to leave the area to get help. The initial assessment by a registered nurse documented minor scratches and a small burn, which the resident declined treatment for at the time. A subsequent assessment noted a burn mark consistent with a cigarette burn that was not initially observed. The resident who was the victim of the abuse had a history of depression, anxiety, and paraplegia, requiring substantial assistance with activities of daily living. His care plan included interventions for verbal aggression and agitation, but there was no indication of behaviors that would have predicted the escalation to physical abuse. The assailant, also cognitively intact, had a care plan noting a potential for anger and aggression if provoked, with interventions for monitoring and de-escalation. However, staff interviews indicated that neither resident was known for physical aggression, and the incident was unexpected by those familiar with their behaviors. The facility's policy required supervision and interventions to prevent abuse, but at the time of the incident, there was no staff supervision in the smoking area, and the camera in that area was not functioning. Witness interviews revealed that not all potential witnesses were interviewed as part of the investigation. The lack of staff presence and incomplete witness interviews contributed to the failure to prevent and fully investigate the abuse incident, resulting in a substantiated finding of resident-to-resident physical abuse.