Failure to Prevent Resident-to-Resident Physical Abuse in Hallway
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse by another resident. One resident with dementia and severe cognitive impairment, who had no documented history of verbal or physical behaviors toward others, was care planned for impaired cognitive ability with interventions such as cueing, orienting, and supervision as needed. Another resident, also with dementia and severe cognitive impairment, had a care plan identifying risk for behavioral changes related to dementia and a separate care plan identifying risk for physical aggression during ADL care and showers, including monitoring for behaviors in the dining area and for touching/striking other residents or staff. On the date of the incident, both residents were seated in a hallway surrounded by other residents when an altercation occurred. An event progress note documented that one resident was heard yelling at another, while the other resident was also yelling and hitting the first resident across the chest with a stuffed animal. The note further documented that the first resident then kicked the second resident in the leg. A similar event note for the second resident described the same sequence of events from that resident’s perspective. Skin assessments completed for both residents on the same day showed intact skin with no redness or bruising. The Assistant DON reported hearing screaming outside her office and then witnessing one resident hitting the other across the chest with a stuffed animal and the other resident kicking back. She stated that she was the only staff member to witness the incident and that she would consider the incident to be abuse. The facility’s 5‑day investigation report verified the allegation based on the evidence collected and noted that both residents were unable to recall the incident. The facility’s abuse‑prevention policy stated that procedures include identification, assessment, and care planning for appropriate interventions and monitoring of residents with needs and behaviors that might lead to conflict, including verbally and physically aggressive behaviors. Despite this, the altercation occurred between the two residents, constituting a failure to protect one resident’s right to be free from abuse by another resident.
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