Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse by another resident, resulting in substantiated abuse incidents involving two residents. Facility policy dated September 2022 states that each resident has the right to be free from abuse, including abuse by other residents, and defines abuse as willful, meaning the individual acted deliberately even if they did not intend to cause harm. Despite this policy, a resident with a history of agitated behaviors (Resident 3), who had severely impaired thinking and memory and was on antipsychotic and antidepressant medications, engaged in two separate physical altercations with other residents on the same day. In the first incident, Resident 3 used both hands to grab another resident (Resident 2), who also had severely impaired thinking and memory, by the hair and shook them hard. A Resident Care Manager (RCM) was present, separated the residents, and questioned Resident 3, who claimed that Resident 2 had stolen their phone. The investigation determined this claim was untrue, as staff had picked up Resident 3’s dropped phone during an activity and returned it shortly thereafter. Resident 2 was assessed and found to have no injuries and no recollection of the incident, but the facility’s investigation substantiated this event as physical abuse. Approximately 40 minutes later, while the RCM remained with and monitored Resident 3, a second incident occurred in which Resident 3 reached out and grabbed another resident (Resident 1) by the left arm while Resident 1 was in a wheelchair talking with a nearby resident. Resident 1, who had intact thinking and memory, reported that they had not been interacting with Resident 3 and only became aware of them when they felt their arm being grabbed and pulled hard. This action caused a skin tear on the left arm measuring 3.5 cm by 3.0 cm and multiple bruises on the same arm, which required wound care and monitoring until resolved. The facility’s incident investigation substantiated this event as physical abuse, and staff interviews noted Resident 3’s history of temper, mood swings, and recent refusals of prescribed psychotropic medications in the days preceding the incidents.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.