Failure to Prevent Repeated Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse during resident-to-resident altercations on consecutive days. Facility policy on abuse prevention states that residents have the right to be free from abuse, including physical abuse, and that administration will protect residents from abuse by anyone, including other residents, and protect residents during abuse investigations. Despite this policy, one cognitively intact resident with bipolar disorder and depression with psychotic features (Resident #81) and another resident with Alzheimer's disease, dementia with behavioral disturbances, major depressive disorder, and anxiety disorder (Resident #2) engaged in physical aggression toward each other without effective prevention of further contact. On the first day, documentation and interviews showed that Resident #81 was walking in the hallway with a walker when Resident #2, in a wheelchair, passed by. Resident #81 accused Resident #2 of stealing her soda, and Resident #2 then ran her wheelchair into Resident #81's walker. A CNA intervened and began pushing Resident #2 back to her room, during which Resident #2 reached out and hit Resident #81 on the leg. Nursing notes and the facility incident report documented that both residents were then taken to their rooms and that no injuries were observed at that time. The LPN and CNA interviews were consistent in describing that Resident #2 physically struck Resident #81 during the separation. On the following day, the same LPN documented that Resident #2 was again propelling herself in the hallway when Resident #81 came out of her room and kicked Resident #2 in the leg as she passed. Resident #2 yelled out in response, and when questioned, Resident #81 admitted to kicking Resident #2, stating she did so because Resident #2 had hit her the previous day and stolen her soda and that she was not sorry. The LPN assisted Resident #2 back to her room while Resident #81 remained in her room to finish breakfast. The administrator confirmed being notified of both physical altercations at the times they occurred and that there were no injuries, but the incidents demonstrated that the facility did not effectively protect either resident from physical abuse by the other resident as required by its abuse prevention policy.
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