Failure to Prevent Resident-on-Resident Physical Abuse in Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal and physical abuse by another resident, despite a known history of aggressive behaviors. One resident (R2) had multiple neurological and psychiatric diagnoses, including pseudobulbar affect, severe intellectual disabilities, cognitive impairment, bipolar disorder, and conversion disorder with seizures, and was documented as rarely or never understood on the most recent MDS. Another resident (R6) had severe cognitive impairment with a BIMS score of 3, along with Alzheimer’s disease, dementia, depression, morbid obesity, and other medical conditions. Both residents were present in the dining room at the time of the incident. On the date of the incident, an incident report documented that R6 approached R2 in the dining room while R2 was shouting, became upset, yelled at R2, and then hit R2 in the face multiple times, leaving a scratch on R2’s nose. A CNA witness stated that she entered the dining room to report off to another CNA, observed R6 standing beside R2, heard R2 begin to yell, and then saw R6 grab R2 by the sweatshirt and hit R2 three to four times on the forehead before the CNA separated them. The CNA reported that she was aware R6 had a history of altercations with other residents and believed R6 was not to be left unattended in the dining room or placed next to other residents there, and she did not see any other staff member observing R6 in the dining room at the time. Record review showed that R6 had multiple prior documented incidents of physical aggression toward other residents, including accusations of physical aggression, altercations and hitting in the dining room, slapping another resident in the dining room, throwing a plastic bottle at another resident in the dining room, and hitting a roommate. R6’s care plan identified behavioral issues such as physical aggression toward staff and other residents, yelling, hitting, wandering into other residents’ rooms, and resistance to care, but the interventions listed were time-limited (such as 1:1 care until infection ruled out and frequent checks) and had been resolved before the incident. The care plan did not include interventions specifically aimed at preventing altercations in the dining room. The Nursing Home Administrator confirmed R6’s prior altercations in the dining room and could not provide evidence of care plan interventions implemented after each altercation or in place prior to the incident to prevent R6’s behaviors and potential physical altercations, despite a facility policy requiring identification, ongoing assessment, care planning, and monitoring of residents with behaviors that might lead to conflict or neglect.
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