Failure to Inform Staff of Resident-to-Resident Altercation and Abuse Allegation
Penalty
Summary
The facility failed to ensure thorough investigation and appropriate corrective action of an abuse allegation following a resident-to-resident altercation involving Resident 1 and Resident 6. Resident 1, who had severe cognitive impairment with a BIMS score of 5 and diagnoses including unspecified dementia, was alleged in the psychosocial care plan dated 1/5/26 to have grabbed her roommate’s wrists and hands and squeezed them hard after attempting to use the roommate’s wheelchair. Resident 6, who had intact cognition with a BIMS score of 14 and diagnoses including abnormality of gait and mobility, reported to the Social Service Assistant that her roommate grabbed her arm while reaching for a wheelchair positioned between their beds. The Assistant Director of Nursing stated Resident 1 was transferred from the fourth floor to the third floor due to this altercation. Despite this, key direct-care staff on the receiving unit were not informed of the incident or the behavior. The CNA assigned to Resident 1 on the third floor stated she did not know why Resident 1 was transferred and only reported that Resident 1 had episodes of anger and grabbing staff. The licensed nurse assigned to Resident 1 on the third floor similarly stated she did not know the reason for the transfer. Another CNA stated that the CNA assigned to a resident involved in an altercation should know about the incident in order to monitor the resident with the behavior and prevent another altercation. The Social Service Assistant and the ADON both stated that staff should be aware of such incidents and resident behaviors for safety reasons. The facility’s abuse, neglect, exploitation, and misappropriation prevention policy indicated residents have the right to be free from abuse and that the program is intended to protect residents from abuse, including from other residents, but staff on the new unit were not made aware of the prior altercation or behavior.
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