Failure to Prevent Resident-to-Resident Physical Abuse on Patio
Penalty
Summary
The facility failed to protect a resident from physical abuse when one cognitively intact resident struck another in the face while on the facility patio. Resident 3, who had COPD, heart failure, and type 2 diabetes and was assessed as cognitively intact with the capacity to make decisions, was seated on a patio chair interacting with other residents, including Resident 4. At approximately 10:55 a.m., while Resident 3 was conversing with the group, Resident 4, who was seated in a wheelchair in front of Resident 3, suddenly stood up and used a closed fist/hand to hit Resident 3 in the right upper eye area without warning. Resident 3’s assessments indicated that cognition was intact and that the resident required supervision or touching assistance for most ADLs. Following the incident, documentation on an SBAR form and a skin assessment described a linear cut above the right eye, initially measured at 0.5 cm in length by 0.1 cm in width and depth, with small bleeding and reddish discoloration. Subsequent observation by the ADON noted purplish discoloration around the right eye and a laceration approximately 1.0 cm in length by 0.1 cm in width and depth, covered with steri-strips. Resident 3 reported aching pain in the right eye area, rating it 2 out of 10, and expressed being shocked that the incident occurred. Resident 4’s records showed that this resident was also cognitively intact, had decision-making capacity, and required setup or clean-up assistance for most ADLs. On the date of the incident, Resident 4 was on the patio interacting with other residents, including Resident 3, in the presence of an activity staff member (ACS 1). The SBAR for Resident 4 and ACS 1’s interview indicated that Resident 4 suddenly stood up, raised a hand toward Resident 3, and, despite ACS 1’s attempt to intervene, struck Resident 3 in the right eye area. In a subsequent report to the state agency, Resident 4 stated that he felt his hand make contact with Resident 3’s face. The facility’s abuse policy stated that residents have the right to be free from abuse and that willful non-consensual contact between residents is considered abuse and is never to be deemed unavoidable.
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