Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The deficiency involves the facility’s failure to prevent abuse between two cognitively intact roommates, resulting in one resident sustaining injuries that required emergency room evaluation. One resident (R1), with diagnoses including bipolar disorder with psychotic features and hallucinations, was known to talk to himself, laugh, and swear in response to auditory and visual hallucinations. On the evening of the incident, R1 was in the shared room talking to himself and responding to his voices while the other resident (R2), who has major depressive disorder, suicidal ideation, alcohol abuse, and a history of criminal behavior, was also in the room watching television. R2 became annoyed by R1’s behavior and told him to keep it down. Accounts differ on who threw liquid first, but both residents reported that liquid was thrown or poured, followed by a physical altercation. According to interviews and progress notes, R1 and R2 began yelling and then physically fighting, moving from their room into the hallway. Staff, including an RN and CNAs, heard a commotion and yelling and then observed R2 lying on the floor in the hallway with R1 on top of him, punching him in the face. Witnesses described the residents “punching and fighting with each other” before staff intervened. R1 later stated he punched R2 in self-defense after R2 threw a cup with liquid and punched him, while R2 stated that R1 came to his side of the room, got in his face, threw water at him, hit the side of his head, gave him multiple swings, pushed him to the floor, got on top of him, and continued punching. As a result of the altercation, R2 sustained bruising to the left temple, bleeding above the eye and lip, and required emergency room evaluation, while R1 had scratches to the right eyelid, chin, and forearm. The facility’s abuse policy defines abuse as physical or mental injury inflicted on a resident other than by accidental means and specifies that resident-to-resident altercations should be reviewed as potential abuse. The DON and Administrator both stated that, based on the facility’s investigation, the allegation of abuse was substantiated and acknowledged that it is the facility’s job to prevent abuse, indicating that the facility did not prevent this resident-to-resident physical abuse incident from occurring.
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