Failure to Prevent and Assess Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident, as required by its Abuse Prevention and Reporting policy. The policy states that residents have the right to be free from abuse, including physical abuse such as hitting, slapping, pinching, and controlling behavior through corporal punishment, and that staff must identify residents with increased vulnerability, triggers, and behaviors that might lead to conflict through admission assessments, comprehensive care plans, and MDS assessments. Staff are required to use the care planning process to identify problems, goals, and approaches to reduce the chances of abuse and to monitor and update these on a regular basis. In this case, the facility did not complete abuse or behavioral assessments after a resident-to-resident altercation, and there was no skin assessment or care plan update or revision for the injured resident following the incident. On the date of the incident, an LPN heard a commotion in a shared room and observed both roommates physically touching each other, with one resident in a wheelchair and the other on the bed. One resident complained that the other was on her side of the room and bothering her belongings, while the other responded confrontationally. The LPN removed a hanger both residents were holding, separated them into the hallway, and then observed that one resident’s forearm was bloody, with apparent nail marks and superficial scratches that were cleansed and treated with triple antibiotic ointment. Interviews indicated that one resident had a history of aggressive behaviors and that the altercation occurred when one resident was going through the other’s personal belongings and wanted the remote, leading to the scratching. Another roommate reported that the aggressive resident hits and screams at staff during ADL assistance. The DON confirmed that the injured resident received fingernail scratches to the right forearm and that no behavioral services, behavioral assessments, or abuse assessments were completed for the aggressive resident after the interaction.
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