Failure to Prevent Resident-to-Resident Physical Altercation Related to Alcohol Use
Penalty
Summary
The deficiency involves the facility’s failure to implement adequate supervision and interventions to prevent a resident-to-resident physical altercation. Resident 1, who had a diagnosis of rectal cancer and depression and a BIMS score of 15 indicating intact cognition, reported that while sitting in a wheelchair in their room, Resident 2 entered the room in a wheelchair, appeared to be under the influence of alcohol, and spoke loudly. Resident 1 stated they repeatedly asked Resident 2 to leave, but Resident 2 did not comply, then stood up, approached, and punched Resident 1 on the right side of the face, resulting in facial redness and causing Resident 1 to feel upset. Resident 1 stated the facility was aware of Resident 2’s alcohol use and associated behaviors but failed to adequately monitor and implement interventions to prevent Resident 2’s physical aggression. Record review showed Resident 2 had a diagnosis of alcoholic cirrhosis of the liver with ascites, and progress notes documented that staff had previously noted Resident 2 with slurred speech and had intervened regarding alcohol use. An SBAR note documented that the altercation occurred at 4:30 p.m., that Resident 1 reported Resident 2 looked drunk, entered the room, talked loudly, and hit Resident 1 in the face, and that Resident 2 was suspected of consuming alcohol earlier that afternoon. The Social Worker stated they were aware of Resident 2’s alcohol use and aggression and that staff should have monitored Resident 2 if alcohol use was suspected due to unpredictable behavior toward others. The Administrator stated they were aware of Resident 2’s alcohol use, observed Resident 2 partially inside Resident 1’s doorway just before hearing yelling, then found Resident 1 with redness on the right side of the face and later found a full bottle of alcohol in Resident 2’s room. The facility’s Abuse Prevention Program policy stated residents have the right to be free from abuse by anyone, including other residents.
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