Failure to Prevent Resident-to-Resident Physical Abuse on Patio
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse by another resident, resulting in a physical altercation with documented injuries. One resident, identified as having severe to moderate cognitive impairment, multiple serious medical conditions, and using a manual wheelchair, was involved in an incident on the facility patio with another resident. The resident’s clinical record showed a history of rejecting care on some days and being at risk for falls due to decreased mobility and strength. On the date of the incident, nursing documentation reflected that the resident’s primary physician and nurse practitioner were notified about an event involving another resident. The other resident involved in the altercation had a history of diffuse traumatic brain injury, schizoaffective disorder, major depressive disorder, seizures, hemiplegia, and other conditions, with a BIMS score indicating moderate cognitive impairment. This resident’s care plan, initiated months before the incident, identified verbal and physical aggression, intrusive behaviors, and outbursts, and included the January altercation as part of the behavioral focus. Orders in place required behavior charting on day and evening shifts. A nursing progress note documented behavior issues for this resident around the time of the incident, noting that he was redirected to his room. On the day of the event, during a nursing shift change, staff heard residents on the patio calling for help. When LPN staff responded, the two residents had already stopped fighting and were back in their wheelchairs, with other residents present who had witnessed the altercation. One cognitively intact resident witness reported that the alleged victim verbally confronted the other resident, who then stood up from his wheelchair, grabbed the resident, and engaged in a physical fight until other residents intervened and called for help. The resident identified as the aggressor admitted that he instigated the physical altercation, held the other resident down, and continued fighting until separated. Subsequent assessment documented that the victim had a knot on his left hand, a bruise and scrape on his right hand, a scrape on his right knee, and a bruise with two knots on his left leg. The facility Administrator and Abuse Coordinator stated that unwanted physical contact met the definition of physical abuse and that this incident constituted abuse and did not meet facility expectations, despite a written policy requiring an environment free from abuse.
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