Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from physical abuse during a resident-to-resident altercation. One male resident with moderate cognitive impairment and a history of traumatic brain injury reported that his roommate became upset over closet space and became physical with him. The incident was witnessed by an LPN, who observed the two residents arguing, followed by one resident swinging his hand and hitting the other in the face, resulting in an abrasion under the left eye and a small amount of blood in the mouth. The altercation was reportedly unprovoked, and there was no prior history of altercations between the two residents. The roommate involved in the altercation had severe cognitive impairment, a history of aggressive or inappropriate behavior, and diagnoses including Parkinson's disease, dementia, and schizoaffective disorder. According to staff interviews, the roommate believed his belongings were being taken and was searching the other resident's closet. The situation escalated to a physical confrontation, which was not prevented by staff despite the roommate's known behavioral history. The facility's abuse policy affirms the right of residents to be free from abuse and outlines the responsibility to prevent such occurrences. Staff responded after hearing the commotion, intervened to separate the residents, and provided immediate care for the injury. However, the incident demonstrated a failure to intervene before physical abuse occurred, despite the presence of risk factors and a care plan that included staff intervention during verbal altercations. The deficiency was identified through interviews, record reviews, and direct observation, confirming that the facility did not fully protect the resident from abuse as required.