Failure to Prevent Resident-to-Resident Physical Abuse Involving a Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident (R2) from resident-to-resident physical abuse in accordance with its abuse prevention policy. R2, an elderly female with dementia, severe cognitive impairment (BIMS score 4/15), anxiety, and behavioral disinhibition, had a history of wandering into other residents’ rooms and difficulty with redirection, as documented in nursing notes and psychiatric evaluations. Despite these known behaviors, R2 continued to wander and enter other residents’ rooms, including being described as going to other residents’ rooms, fighting with staff when redirected, and having decreased tolerance for environmental stimulation and personal space intrusions. On the date of the incident, R2 wandered into the room of another confused resident, R1, who was attempting to leave her room as R2 was entering. R1 reported that a lady came into her room, would not leave despite being told to get out, and that she began yelling and trying to push the lady out. R1 stated she felt bad about hitting the other resident in the face but said she was trying to get her out of the room when the resident would not listen. Staff witnesses reported hearing a loud noise and voices from R1’s room and, upon arrival, found that an altercation had already occurred in which R1 had hit R2 in the face. Following the altercation, staff assessments documented that R2 had a small open area or scratch/redness under the left eye, with no bleeding, bruising, swelling, or reported pain, and that R2 was calm and not in distress. R1 was assessed and found to have no injuries. Interviews with nursing and social services staff confirmed that R2 had become lost and confused and attempted to enter R1’s room, leading to a disagreement and R1 striking R2 in the face before staff could intervene. The facility’s abuse prevention policy requires protection of residents from all forms of abuse, including resident-to-resident abuse, but the facility did not adequately identify and intervene to prevent this resident-to-resident physical abuse incident involving R2 and R1.
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