Failure to Prevent Resident-to-Resident Abuse Following Prior Altercation
Penalty
Summary
The facility failed to protect residents from physical and verbal abuse by not implementing effective interventions following a prior altercation between two residents. Despite a previous incident where one resident pushed and kicked another, resulting in a reported injury, the facility did not update care plans or establish measures to keep the residents apart or address the ongoing risk of further altercations. Both residents had documented histories of behavioral and mental health issues, including anxiety, depression, and bipolar disorder, and were assessed as having intact cognition. On a subsequent occasion, the same two residents were involved in another physical altercation. Staff, including the ADON and NP, observed the residents exchanging words in a negative tone and attempted to intervene, but were unable to prevent the escalation. One resident repeatedly rammed their wheelchair into the other, who then responded by striking the first resident in the face, causing a bloody nose and requiring emergency department evaluation for blunt trauma. The incident was witnessed by staff, and both residents expressed distress following the event. Record reviews and interviews confirmed that after the initial altercation, there were no specific interventions or care plan updates to prevent further incidents between the two residents. The DON acknowledged that neither resident's care plan or Kardex included instructions to keep them apart or protect them from each other, even after two documented altercations. This lack of action resulted in actual physical and psychosocial harm to the residents involved.