Failure to Protect Residents From Abuse During Resident-on-Resident Altercations
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse when resident-on-resident altercations occurred. In the first incident, a certified nursing assistant (CNA) witnessed one resident strike another resident on the top of the head. Documentation showed the resident who was struck was assessed and found to be free of injury. The resident who committed the act had a Brief Interview for Mental Status (BIMS) score of 1, indicating severe cognitive impairment, while the resident who was struck had a BIMS score of 12, indicating moderate cognitive impairment. The incident was reported on an OSDH incident report form, and nursing notes documented the aggressor’s status and supervision level following the event. In the second incident, another CNA witnessed a resident knock the glasses off another resident’s face. The resident whose glasses were knocked off was assessed and found to be free of injury and had an Alzheimer’s diagnosis and was described as unaware of their own actions. The resident who committed the act had a BIMS score of 15, indicating they were cognitively intact. The incident was captured on camera and documented on an OSDH incident report form. Interviews with an LPN and the DON indicated that the cognitively intact resident had been placed in memory care due to family concerns about elopement and that the other involved residents had varying levels of cognitive impairment and behavioral concerns. These events formed the basis of the finding that the facility failed to protect residents from abuse.
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