Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Skin Tears
Penalty
Summary
The facility failed to protect a resident from abuse by another resident when a cognitively intact resident with a known history of resident-to-resident and resident-to-staff altercations engaged in a physical altercation with a cognitively impaired resident. The alleged perpetrator had diagnoses including depression, psychosis, anxiety, and dysphagia, and a recent MDS showed a BIMS score of 15, indicating intact cognition. This resident’s care plan documented a confirmed history of altercations and included an intervention to remove the resident from the environment when verbal escalation began. Despite this, the resident was able to approach another resident in the hallway and initiate an aggressive interaction. On the date of the incident, staff documented that the alleged perpetrator and the alleged victim were in the hallway when the perpetrator verbally challenged the other resident by saying, "Do you want to fight?" and then advanced toward the resident and scratched the resident’s left arm. The cognitively impaired resident, who had diagnoses including dementia, hypertension, chronic kidney disease, and depression and an MDS BIMS score of 7 indicating significant cognitive impairment, backed away and stated that she had done nothing and was just standing there when scratched. Social services documentation described three superficial skin tears approximately 3 mm by 3 mm on the victim’s left arm with a small amount of bleeding and reported that the resident experienced pain at the injury site. Facility interviews and documentation confirmed that the incident was substantiated as physical abuse. The DON and the administrator acknowledged that the aggressive behavior by the perpetrating resident toward the cognitively impaired resident in the hallway constituted physical abuse. The facility’s abuse and neglect policy stated that residents are to receive care in an environment free from any type of abuse, including physical abuse. Staff interviews indicated awareness that such an incident would be considered abuse and that responsibility for preventing it rested with facility employees, yet the event still occurred, resulting in the resident-to-resident physical altercation and injury.
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