Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving three out of six residents reviewed for abuse. In one incident, a resident with unspecified dementia and anxiety was bitten on the wrist by another resident with severe dementia, behavioral disturbances, and other neurological and psychiatric diagnoses. The biting incident resulted in a bruise, and in response, the first resident grabbed the other by the shirt and slapped them on the face. Staff witnessed the altercation, and documentation confirmed the physical interactions and resulting injuries. Another incident involved a resident with dementia and behavioral disturbances who was struck on the shoulder by a recently admitted resident with severe cognitive impairment and a history of traumatic brain injury, bipolar disorder, and major depressive disorder. The striking occurred as the first resident was walking by the second resident's room, leading to a loss of balance and a fall that resulted in a right hip fracture. Witnesses, including CNAs and a wound care nurse, confirmed the sequence of events and the resulting injury. The resident who initiated the physical contact stated they were trying to prevent the other from entering their room. The facility's abuse prevention policy defines abuse as the willful infliction of injury or intimidation resulting in physical harm or mental anguish. Despite this policy, the incidents described demonstrate that the facility did not effectively prevent resident-to-resident abuse, as evidenced by physical altercations resulting in injuries such as bruising and a hip fracture. The report includes direct observations and statements from staff and residents involved in the incidents.