Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to follow its abuse prevention policy, resulting in a resident with cognitive impairment and multiple medical conditions sustaining physical injuries. The resident, who required maximal assistance with activities of daily living and was unable to ambulate, was involved in a physical altercation with another resident known to have a history of violent behavior and psychotic disturbances. The incident took place in a common area, where the aggressive resident struck the vulnerable resident multiple times in the facial area, causing bruising and swelling to the right eye and face. Staff interviews and clinical records confirm that the aggressive resident had previously exhibited physical aggression toward other residents and staff, and was being monitored for such behaviors. During the incident, staff responded after hearing commotion and yelling, intervening to separate the residents. The injured resident was promptly sent for an emergency eye appointment, and the aggressor was placed on one-to-one monitoring and later transferred for psychiatric evaluation. However, the facility's abuse policy required identification and prevention of potential mistreatment, which was not effectively implemented in this case, as the aggressive resident was able to physically harm another resident. The investigation revealed that the administrator could not recall the details or outcome of the incident investigation, despite the abuse allegation being substantiated. Documentation showed that the facility had policies affirming residents' rights to be free from abuse and required timely investigation and reporting of such incidents. The failure to prevent the altercation and protect the resident from physical harm constituted a breach of the facility's abuse prevention policy.