Failure to Prevent Resident-to-Resident Physical Abuse in Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and intervention to prevent physical abuse between residents, resulting in one cognitively impaired resident physically striking another during a meal. The facility’s abuse, neglect, and exploitation policy requires deployment of trained and qualified staff in sufficient numbers who know residents’ care needs and behavioral symptoms, and mandates prevention of all types of abuse. Despite this, staff interviews and the facility’s own investigation showed that staff were aware of one resident’s frequent behavior of reaching for and taking other residents’ desserts, and another resident’s territorial behavior and history of becoming aggressive when his belongings or food were disturbed. On the date of the incident, both residents, each with severe cognitive impairment and behavioral histories, were seated together at the same dining table. During the meal, the cognitively impaired resident with a history of grabbing desserts reached out and took the other resident’s dessert. In response, the territorial resident slammed his hands on the table, hit the dessert-taking resident in the chest, and called him names. A CNA witnessed the event and confirmed that the altercation occurred immediately after the dessert was taken. The facility’s investigation documented that both residents had severe cognitive impairment with behaviors and concluded that physical abuse had occurred. Record review showed that the victim resident had diagnoses including cognitive, social, or emotional deficit following cerebral infarction, mood disorder due to a physiological condition, generalized muscle weakness, and lower leg contractures, and was totally cognitively impaired with a BIMS score of 0, requiring maximum assistance with all ADLs. His care plan addressed impaired cognitive function and communication strategies but did not document his behavior of reaching for other residents’ desserts. The assailant resident had dementia with psychotic, mood, and anxiety components, cognitive impairment with a BIMS score of 5, and a care plan noting confusion, delusional thought processes, and a suspected trauma history contributing to possessiveness of space and reactive responses. Staff interviews confirmed that this resident was territorial over belongings, became aggressive if someone took his food, and had a history of verbal threats and attempts to hit or grab when close to others. The NHA acknowledged that the victim’s dessert-seeking behavior was not care planned and that the two residents, given their known behaviors, should not have been seated together, leading to the abusive incident.
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