Failure to Prevent Resident-to-Resident Altercation Resulting in Injury
Penalty
Summary
The facility failed to prevent a resident-to-resident altercation involving two residents, resulting in one resident sustaining a minimally displaced fracture to the left nasal bone. One resident, who had a history of hemiplegia, hemiparesis, and unspecified psychosis, was documented as being verbally aggressive toward others but had no care plan addressing abuse. This resident reported being physically attacked by his roommate, who struck him multiple times, prompting him to retaliate with a single blow. Both residents were separated immediately after the incident, and assessments were conducted. The other resident involved had a history of cerebral infarction, major depressive disorder with psychotic features, and significant cognitive impairment, as indicated by a low BIMS score. This resident was known to resist care and had a history of making false statements about being hit by others, but there was no care plan addressing abuse for this individual either. During the altercation, this resident sustained a nasal fracture, as confirmed by a CT scan, and required emergency medical evaluation and treatment. Documentation indicated that this resident was combative with care on a daily basis and had functional limitations on both sides. The facility's records and interviews revealed that neither resident had a care plan specifically addressing abuse, despite documented behavioral concerns and histories of aggression or combative behavior. The incident was not witnessed by staff, but was reported and documented after the fact. The facility's policy stated a commitment to protecting residents from abuse by anyone, including other residents, but the lack of individualized abuse prevention care plans contributed to the failure to prevent this altercation.