Failure to Prevent Resident-to-Resident Physical Altercation Over Personal Belongings
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from resident-to-resident physical abuse when two residents engaged in a physical altercation. One resident with Alzheimer’s disease and generalized anxiety disorder, who was severely cognitively impaired with a BIMS score of 0/15, frequently walked around the unit and picked up items in her environment. Her care plan identified that she spent time walking around the unit picking up sensory items and directed staff to offer cues and prompts as needed, but there was no care plan addressing her behavior of picking up other residents’ belongings. On the day of the incident, this resident walked by another resident in the dining area and picked up a pair of gloves that were next to the second resident, then walked away carrying the gloves. The second resident involved had unspecified dementia, major depressive disorder, and a history of suicidal ideation, with a BIMS score of 12/15 indicating moderate cognitive impairment. Her care plan identified risk for psychosocial well-being concerns related to suicidal ideation and included an intervention to remove residents to a calm, safe environment when conflict arises, but there was no care plan addressing her frustration with peers. A family member witness reported that after the first resident picked up the gloves and began walking down the hall, the second resident followed, forcefully grabbed the first resident’s arm, and pulled back in a way that caused the first resident to turn around. In response, the first resident slapped the second resident on the side of the face, after which the second resident appeared angered and verbally stated that she had been slapped. Staff interviews and documentation further described the residents’ behaviors and the circumstances leading to the altercation. An LPN stated that the first resident frequently explored her environment by picking up items and did not have the capacity to consider ownership of the items she handled. A CNA reported that the second resident felt frustrated by the actions of other residents and would respond by yelling at them. A progress note documented that the second resident had been upset about a disagreement with another resident over her gloves, and a later psychiatric evaluation noted that she argued with another resident and had current symptoms including anxiety, depression, and irritability. The facility’s Resident Rights, Abuse and Neglect policy defined physical abuse to include hitting, slapping, and grabbing, and the reasonable person concept was applied to determine that neither resident would want to be grabbed forcefully by the arm or slapped in the face, establishing that the resident-to-resident physical contact constituted abuse that the facility failed to prevent.
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