Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from physical abuse by another resident. The incident took place in the dining area, where two residents, both using wheelchairs, were involved in an altercation. One resident attempted to pass by another but was unable to due to limited space. This led to the resident becoming frustrated, standing up from the wheelchair, and striking the other resident in the face. The assaulted resident sustained two superficial scratches to the face as a result of the incident. Both residents involved had intact cognition as indicated by their BIMS scores, and neither had a prior history of altercations with each other. The resident who was struck reported feeling upset by the event but did not require hospitalization and denied any pain. The incident was witnessed by staff and other residents, who confirmed that the aggressor became frustrated when unable to pass and initiated the physical contact. The facility's abuse prevention and resident rights policies prohibit any form of abuse, including physical injury inflicted by anyone. The deficiency was identified through observation, interviews, and record review, which documented that the facility did not prevent the occurrence of resident-to-resident physical abuse. The event resulted in minor physical injury to one resident and was corroborated by multiple sources, including staff, residents, and medical records. The facility's failure to ensure a safe environment free from abuse for all residents led to this deficiency.