Failure to Prevent Multiple Resident-to-Resident Physical Abuse Incidents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from resident‑to‑resident physical abuse on the behavioral unit and other units, resulting in multiple altercations. One incident involved a resident with schizoaffective disorder and moderate cognitive impairment who was asleep in bed when she awoke to another resident, also diagnosed with schizoaffective disorder and anxiety disorder, standing over her with gloved hands placed over her mouth and nose and pushing down. The sleeping resident reported that the other resident was trying to kill her and yelled for her to get out of the room. Staff, including an LPN and a CNA at the nurses’ station, heard the yelling, observed the alleged aggressor coming up the hallway wearing medical gloves, and were informed by the victim that the aggressor had tried to cut off her breathing. Multiple staff interviews documented that the alleged aggressor did not deny placing her hands over the other resident’s mouth and nose and, in some accounts, demonstrated how she did it and stated she had planned it because she believed the other resident had taken fentanyl patches. A second incident involved a resident with severe dementia, expressive aphasia, and a history of cerebral infarction, who had care plan interventions for communication deficits and pain assessment. Another resident with dementia, cognitive communication deficit, and a care plan identifying wandering, verbal aggression, physical aggression, and resisting care was observed entering the first resident’s room. A CNA reported seeing the aggressive resident block the other resident in the room with her wheelchair in a corner and, before she could intervene, saw the aggressive resident kick the other resident above the knee. Nursing documentation confirmed that the resident was kicked by another resident, with no injury or complaints of pain noted at that time. A third incident occurred a few hours later and involved the same aggressive resident and another resident with unspecified dementia with behavioral disturbance, Alzheimer’s disease, seizures, generalized anxiety disorder, major depressive disorder, atrial fibrillation, delusional disorder, and chronic heart failure, who was severely cognitively impaired and care planned as at risk of abuse/neglect related to dementia. A CNA sitting at the nurses’ station witnessed the aggressive resident self‑propel her wheelchair behind this resident, who was seated in a wheelchair, and slap her on the back. The CNA separated the residents and notified nursing and administration. Progress notes and the facility’s incident reports documented that the aggressive resident had hit another resident in the back and that these were resident‑to‑resident altercations. Across these events, the facility’s abuse prevention policy defined abuse as the willful infliction of injury, intimidation, or punishment causing physical harm, pain, or mental anguish, and required steps to prevent further potential abuse while investigations were in progress, but the incidents demonstrate that residents were not kept free from physical abuse by other residents.
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