Failure to Prevent Resident-to-Resident Physical Abuse in Dining Room Incidents
Penalty
Summary
The deficiency involves the facility’s failure to prevent resident-to-resident physical abuse, contrary to its abuse prevention policy that affirms residents’ rights to be free from abuse, neglect, and mistreatment by anyone. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and includes deprivation of necessary goods or services. Despite this policy, two separate resident-to-resident altercations occurred, each involving physical contact and resulting in at least minor injury or pain to the residents involved. In the first incident, one cognitively intact male resident with diagnoses including mild intellectual disabilities, schizoaffective disorder, major depressive disorder, and panic disorder approached another cognitively intact male resident with alcohol-induced persisting dementia in the dining room early in the morning. Without provocation from the second resident, the first resident pushed him back against a wall using his hands and his mobility device, causing the second resident to drop his metal cup and spill its contents. Staff responded and separated the residents. The aggressor stated that the other resident was “in his business,” while the victim reported that the event happened quickly and that he had only gone to get ice and a straw. Documentation noted scratches on the victim’s face and an abrasion on his forehead, and the victim later described the event as an act of violence and showed a dented metal cup from the incident. In the second incident, a female resident with Alzheimer’s disease, dementia, anxiety, major depressive disorder, irritability, anger, severe cognitive impairment, and significant functional limitations, who used a wheelchair and was dependent for most ADLs, threw a salt and pepper caddy or plastic sugar container at another female resident. The target resident had severe cognitive impairment, polyarthritis, a history of transient cerebral ischemic attack, hypertension, and mild intellectual disabilities, and required supervision for ADLs. While both residents were seated in their usual dining room locations waiting for dinner, the aggressor became agitated and threw the container, which struck the other resident in the lower back. The struck resident later reported that the impact made her back hurt and that she did not like to be around the aggressor, and another resident witness stated that the throw appeared intentional. These events demonstrate that the facility did not effectively prevent abuse between residents as required by its own policy and regulatory standards.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.