Failure to Prevent Resident-on-Resident Physical Abuse Resulting in Head Laceration
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident, resulting in a head laceration and transfer to an acute care hospital. Resident 1, who had metabolic encephalopathy, unspecified dementia, and daily wandering behavior, was rarely or never understood and could not make himself understood, and a CNA reported that this resident often wandered the hallways and did not have the ability to defend himself. On the day of the incident, Resident 1 was later found in Resident 2’s room, sitting on the floor near the door with active bleeding from a laceration above the left eyebrow. Resident 2 had metabolic encephalopathy, unspecified dementia, and undifferentiated schizophrenia, with a BIMS score of 7/15 indicating severe cognitive impairment. Staff interviews indicated that Resident 2 tended to become agitated when people walked around his room. On the day of the incident, the charge nurse heard commotion and a low voice from Resident 2’s room, which had a closed door. Upon entering, the nurse found Resident 1 bleeding from the forehead and Resident 2 sitting on his bed holding a wooden hanger while using profanity. Although the nurse did not directly witness the strike, he stated it was evident that Resident 2 had hit Resident 1 with the hanger. Progress notes documented that the charge nurse immediately separated the residents and assessed Resident 1, noting bleeding on the left forehead above the eyebrow. Emergency Department provider notes described that Resident 1 had been assaulted with a wooden hanger to the head, resulting in a 3 cm horizontal laceration of the left forehead, which was irrigated and closed with steri-strips. The facility’s abuse prevention/prohibition policy stated that the facility does not condone any form of resident abuse and defined physical abuse as hitting, slapping, pinching, or kicking, but staff acknowledged that although Resident 1’s wandering had been monitored before the incident, they should have been more cautious about his whereabouts.
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