Failure to Prevent Resident-to-Resident Physical Abuse During Smoking Patio Access
Penalty
Summary
The deficiency involves the facility’s failure to prevent resident-to-resident physical abuse between two cognitively intact residents, R1 and R2, during access to the smoking patio. Both residents have multiple medical diagnoses, including nicotine dependence and other chronic conditions, and both have BIMS scores of 15, indicating intact cognition. On the date of the incident, R1 and R2 were proceeding to the smoking area via a ramp and vestibule with a noted blind spot. R2 stopped in the walkway to light a cigarette, which partially blocked the path. R1 attempted to pass and there was physical contact between them, after which a physical altercation occurred resulting in R2 being struck and falling to the ground. Multiple interviews and notes describe differing accounts of who initiated the physical contact, but consistently confirm that R1 hit R2 in the face. R1 reported that while attempting to pass R2 on the ramp, he felt a blow to the left side of his own face, then grabbed R2’s jacket collar, pulled him down, and punched him in the face multiple times before another resident intervened. R2 stated that he was attacked in the vestibule on the way to the smoking tent, reporting that R1 rammed him from behind with a wheelchair, hit him in the right temple area, and threatened to beat him into a coma, and that he did not feel safe. Witnesses, including residents and staff, gave varying accounts: some stated R2 hit or pushed R1 first and R1 hit back, while others stated R2 put his hand in R1’s face and R1 then struck R2, or that R1 grabbed R2, threw him to the ground, and hit him in the face. Clinical documentation and staff observations confirm that R2 sustained visible injury as a result of the altercation. An abuse report noted redness on R2’s upper cheek immediately after the incident, and subsequent nursing and wound care notes described a bruise, black eye, and maroon discoloration on the upper right cheek and around the right eye. R2 was sent to the hospital and admitted with diagnoses including hypotension, facial contusion, dehydration, and lactic acidosis, and later readmitted to the facility with a documented black eye. The facility’s abuse and neglect policy states that physical abuse includes infliction of injury that occurs other than by accidental means and requires medical attention. The survey finding concludes that the facility failed to protect residents from physical abuse, resulting in R2 sustaining an injury near the right eye and requiring hospital evaluation, and that a reasonable person would have experienced psychosocial harm from being injured in this manner.
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