Failure to Protect Resident From Abuse During Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse when one resident slapped another resident on the cheek. The facility’s abuse and neglect policy states that residents have the right to be free from all types of abuse, including physical abuse, and that abusers may include other residents. The resident who committed the slap had an annual MDS showing impaired cognition, dependence on staff for showers, toileting, and transfers, and diagnoses including urinary tract infection, diabetes, and respiratory failure. The resident’s care plan, dated after the incident, later identified that this resident could be a threat to others and could become physically and verbally aggressive, but these interventions were not in place at the time of the event. In the days leading up to the incident, nursing progress notes documented multiple episodes of aggressive behavior by the resident who later slapped another resident. On several dates in December, this resident was noted to be refusing care, hitting, kicking, cursing, yelling at staff, and swinging at them when they approached. Despite these repeated documented behaviors, there were no care-planned interventions for aggressive behaviors toward others in place at the time of the incident. The Assistant Administrator acknowledged that the resident did not have care-planned interventions for aggression because the resident was relatively new and the facility was not aware of the resident’s history, even though the record showed multiple aggressive episodes toward staff prior to the assault. The resident who was slapped had a quarterly MDS indicating impaired cognition, a need for moderate assistance with ADLs such as showering, toileting, and transfers, and diagnoses including dementia, bipolar disorder, and insomnia. This resident’s care plan noted socially inappropriate and disruptive behaviors, including removing clothing in common areas, impaired decision making, and disorganized thinking. On the day of the incident, progress notes and the facility’s self-report documented that the cognitively impaired resident approached the other resident, picked at the resident’s clothing and wheelchair, and touched the resident’s chair and clothes. Before staff could intervene, the seated resident became angry, yelled for the other to go away, and slapped the other resident across the face, causing facial redness. Staff interviews confirmed that the wandering behavior of the victim and the aggressive behavior of the assailant were known, but the assailant’s aggressive behaviors had not been incorporated into the care plan prior to the incident, resulting in a failure to protect the resident from abuse.
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