Failure to Prevent Resident-to-Resident Abuse During Meal Service
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from abuse by another resident during a meal service. The incident involved one resident taking a sugar packet from another resident's dining table, which led to the second resident approaching and physically grabbing the first resident's right arm. This altercation was witnessed by the dietary manager, who reported the event to nursing staff. The affected resident was found to have a pinch mark, bruising, and redness on her right arm, as well as a redness mark at the base of her posterior head. The incident and resulting injuries were documented in the resident's medical record, including photographs and a detailed skin assessment. The resident who initiated the physical contact had a history of behavioral disturbances, including yelling, cursing, and throwing objects when served an inappropriate diet texture. However, prior assessments did not document physical or verbal behaviors directed at others. The resident was cognitively impaired and required behavioral interventions as outlined in her care plan. Despite these interventions, the resident was able to approach and physically harm another resident in the dining room. Interviews with staff and the resident's family revealed that the resident responsible for the altercation had previously entered the dining room unattended, even after being placed on one-to-one supervision following the incident. Observations confirmed that the resident was left unsupervised in the dining area for several minutes before staff intervened. The failure to provide continuous supervision as required contributed to the occurrence of the abuse and the resulting injury to the other resident.