Failure to Substantiate and Protect Resident from Peer-to-Peer Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when an altercation occurred in the dining room and the event was not substantiated as abuse during the facility’s investigation. The involved resident, R3, was an older male with a BIMS score of 8, indicating moderate cognitive impairment, and diagnoses including Type 2 diabetes and unspecified dementia with mood disturbance. During a confrontation in the dining room, R3 approached and invaded another resident’s (R9’s) personal space, and R9 hit R3 in the nose before staff could separate them. R3 was sent for a medical evaluation and returned to the facility. The facility’s abuse policy defines physical abuse to include hitting and similar acts, and the policy states the facility will promote resident security and prevention of mistreatment. The administrator, who served as the abuse coordinator, conducted the investigation and initially concluded the incident was unsubstantiated because he determined that R9 did not show intent to hurt R3, despite acknowledging that contact occurred and that R3 was hit in the nose. Police were notified and came to the facility but did not make a report. The administrator later stated that he should have substantiated the event. The surveyor was unable to obtain statements from the CNAs and social work aide who were first on the scene and separated the residents, despite attempts to contact them by phone. Months after the altercation, R3 experienced a separate incident in the dining room in which he collapsed and was taken to the hospital; this was confirmed as a different event from the altercation in which he was hit in the nose.
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