Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from abuse when two residents were involved in separate resident-to-resident physical altercations. In the first incident, a resident with dementia and adjustment disorder but no documented memory impairment, and with a care plan noting trauma related to prior resident-to-resident abuse, was walking in a hallway when another resident approached from the opposite direction and swung her right arm, striking the resident in the stomach. The aggressor resident had dementia, anxiety, adjustment disorder with depressed mood, a BIMS score of 0 indicating severe memory impairment, and a care plan documenting a history of harm to others, poor impulse control, and prior hitting of another resident. Progress notes documented the altercation, and a CNA witness stated she saw the aggressor resident swing her arm and hit the other resident’s stomach; the victim resident reported being hit and experiencing pain at the time of the incident. In the second incident, a resident with Parkinson’s disease, dementia, Alzheimer’s disease, depression, moderate memory impairment, and a care plan noting trauma related to being a victim of resident-to-resident altercation was in bed when his roommate, who had Alzheimer’s disease, dementia, depression, anxiety, and severe memory impairment, hit him on the left shoulder. Progress notes for both residents documented that the roommate was witnessed hitting the resident’s left shoulder. A CNA reported hearing the resident yelling, entering the room, and observing the roommate hit the resident twice on the left shoulder. The DON acknowledged that residents have the right to be free from abuse and confirmed both incidents of one resident hitting another, despite the facility’s written policy on abuse prevention and reporting of alleged abuse and suspicion of crime intended to ensure residents’ rights are protected and to prevent any type of resident abuse.
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