Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an altercation between two residents. One resident, who had diagnoses including dementia with mood disturbances, heart failure, anxiety disorder, and Parkinsonism, and who had a moderate cognitive deficit, was involved in a physical altercation with another resident diagnosed with neuroleptic-induced parkinsonism, bipolar disorder, and schizophrenia, who was cognitively intact. The incident occurred when the second resident, while in her wheelchair, made contact with the first resident using a closed fist to the side and arm. The first resident then responded by making contact with the second resident's arm. Both residents were separated by staff and assessed for injuries, with no marks, bruising, or redness noted. The care plans for both residents documented behavioral symptoms and previous incidents, including inappropriate comments, threats, and prior altercations. Interventions in the care plans included attempts to keep the residents separated and monitoring for behavioral issues. Despite these interventions, the altercation occurred, and staff responded by separating the residents and assessing them for injuries. The incident was reported to the administrator, physician, and other relevant parties, and documentation was made in the residents' medical records. Interviews with staff indicated that the altercation was witnessed by a CNA, who reported it to an LPN, and subsequently to the administrator. The administrator did not witness the event but was informed by staff. The incident was also reported to the police and the state survey agency. The facility's abuse prevention policy defines abuse as the willful infliction of injury or intimidation resulting in physical harm, pain, or mental anguish, and requires immediate action when such incidents occur.