Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Finger Fracture
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse when another resident threw a chair that caused injury. One resident with schizoaffective disorder, a history of assaultive behavior, poor impulse control, fixated delusional thoughts, and agitation was care planned as being at risk of becoming physically aggressive toward others, with interventions to assess and anticipate needs and intervene before agitation escalates. Another resident with schizophrenia and a history of assaultive behavior was care planned as being at risk for behavioral disturbances, with an intervention to provide a secure and comfortable environment. Both residents were documented as alert, oriented, and able to make their needs known. On the day of the incident, the two residents were in the small dining room waiting for a smoke break. According to nursing notes and staff interviews, the resident with schizoaffective disorder suddenly stood up, lifted the chair she had been sitting on, and threw it toward the other resident, stating she believed the other resident was going to hurt her brother. A mental health worker, positioned at the entry to the dining room to observe residents inside the room and in the hallway, briefly turned away to watch residents passing through the hallway and nurses’ station area. When the worker looked back, the resident had already stood up, grabbed the chair, and thrown it; the worker reported the event happened too quickly to intervene and did not recall any verbal interaction between the two residents immediately beforehand. The resident who was struck reported that she blocked the incoming chair with her hand, describing the chair as heavy with a metal frame and padded seat, back, and armrests. She stated that her ring finger was broken, that it did not hurt at the time of the interview, and that she believed the act was intentional, possibly related to something said previously. Radiology results documented soft tissue swelling and a mild fracture. At the time of surveyor observation, the injured resident had a hard splint from the ring finger to the left elbow wrapped with gauze. Facility policy on abuse, neglect, exploitation, and misappropriation prevention stated that residents have the right to be free from abuse, including physical abuse, and the ADON affirmed that residents should be free from abuse.
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