Failure to Substantiate and Protect Resident from Peer-to-Peer Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when it did not substantiate abuse despite a reported physical altercation and observable signs consistent with being struck. One resident with a history of aggressive behavior and a psychiatric diagnosis reported to a psychiatric mental health NP that they became angry when another resident took their wheelchair and that they hit the other resident, stating they had previously warned they would do so. An internal facility report documented that this resident punched the other resident on the arm as they passed in the hallway, and that staff heard the aggressor curse and admit to hitting the other resident. The resident who was reportedly struck had been admitted with a medical history including wedge compression fractures of thoracic vertebrae 11 and 12, unspecified dementia, anxiety, and repeated falls, and had a BIMS score indicating moderate cognitive impairment. This resident’s care plan identified impaired cognitive function and directed staff to observe for changes in cognitive status. On the night of the incident, staff statements indicated that yelling was heard between the two residents, and that the allegedly abused resident was observed holding their right shoulder/arm. When assessed by nursing staff, this resident was holding their right arm and could not recall what had happened. Despite the aggressor’s admission to staff that they had hit the other resident, corroborating staff observations of verbal aggression and the other resident holding their arm/shoulder, the facility’s investigation concluded that abuse could not be substantiated because no physical or emotional harm was identified. The facility’s abuse protection policy states that each resident has the right to be free from abuse by anyone, including other residents, and defines physical abuse as including hitting. The administrator later confirmed that, even though the resident admitted to hitting and staff observed the other resident holding their arm/shoulder, the facility did not substantiate physical or verbal abuse.
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