Failure to Prevent Resident-to-Resident Physical Abuse Following Room Confrontation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical resident‑to‑resident abuse in accordance with its abuse prevention policy. On the date of the incident, one resident (R4) reported to another resident (R1) that a third resident (R2) had come into R4’s room and flipped or pulled back R4’s bed covers while R4 was lying in bed, which R4 did not like. R4 did not report this interaction to staff but instead told R1, described as a good friend. R4 later stated being surprised by R2 uncovering R4, and did not witness what occurred afterward between R1 and R2. After hearing R4’s account, R1 went to R2’s room to confront R2 about R4. Multiple staff and resident interviews consistently indicated that R1 went to or stood in the doorway of R2’s room, told R2 to leave R4 alone, and refused to leave when R2 asked R1 to go. R2, who has diagnoses including schizophrenia, bipolar disorder, major depressive disorder, and a history of physical and verbal aggression related to hallucinations and serious mental illness, became agitated and struck R1 in the face. R1, who has multiple medical and psychiatric diagnoses including schizoaffective disorder, unspecified psychosis, bipolar disorder, and is care planned as being at risk for abuse related to serious mental illness and impulse control issues, reported that R2 punched the right side of R1’s face. Staff, including an LPN and an RN, described the contact as a slap or hit to the face. The incident resulted in a brief red mark on R1’s face, which staff described as slight redness that resolved after a few minutes. R1, R2, R4, and multiple staff (including the DON, Administrator, Social Services Director, Social Service Aide, LPN, and RN) all confirmed that there was a verbal and physical altercation initiated when R1 confronted R2 about R4 and refused to leave R2’s room, and that R2 responded by hitting or punching R1 in the face. R1’s care plan and abuse risk reviews documented pre‑existing risk factors such as serious mental illness, impulse control issues, verbally threatening behavior, and exposure to trauma, and R2’s care plan and abuse risk review documented a history of physical and verbal aggression, serious mental illness, impulse control issues, and aggression/combative behavior. Despite these identified risks, the facility did not prevent the resident‑to‑resident physical abuse that occurred when R2 struck R1, resulting in the cited failure to protect R1 from abuse.
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