Failure to Assess and Document After Resident-on-Resident Physical Altercation Allegation
Penalty
Summary
The deficiency involves the facility’s failure to implement its policies and procedures for alleged or suspected abuse, change in condition, and charting and documentation after a resident reported being physically assaulted by another resident. One resident, with diagnoses including congestive heart failure, difficulty in walking, Type II diabetes mellitus, and depression, and with intact cognitive skills for daily decision-making, reported that another resident had hit him in the mouth and on the head on multiple occasions over several days and that he had called the police about the most recent incident. The resident required moderate assistance to supervision for ADLs. The alleged aggressor resident had diagnoses including COPD, chronic kidney disease, and dementia, with moderately impaired cognitive skills for daily decisions and a need for moderate to maximal assistance with ADLs. Progress notes for this resident documented ongoing monitoring for repeated physical and verbal aggression toward others and a prior incident of physical aggression in which the resident attempted to hit others with a walker in the hallway. Staff interviews confirmed there was a history of arguments and that the two residents did not get along, and that an incident had occurred a few days prior to the survey. Despite the report of physical aggression, the DON acknowledged that no nursing assessments, such as a skin assessment, were completed for the resident who reported being hit, and that she did not perform a nursing assessment herself. Review of the medical record by the Medical Records Director confirmed there was no nursing documentation related to the allegation, including no change of condition or SBAR documentation to reflect any assessment or monitoring after the report. The Administrator stated that complete documentation with nursing assessment, such as change of condition and/or SBAR, is required when a resident reports any type of abuse or physical aggression. These findings show the facility did not follow its own policies requiring assessment, monitoring, physician and responsible party notification, and documentation when a resident reports alleged abuse or physical altercation.
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