Failure to Prevent and Respond to Resident-to-Resident Physical Abuse in Dining Room
Penalty
Summary
The facility failed to protect a resident from resident-to-resident physical abuse when one resident pushed another resident in the dining room without staff present. One resident (R2) reported that he and his roommate (R1) had a fight in the dining room and that he pushed R1, causing R1 to fall from his wheelchair, although R1 was able to get up on his own. R1 stated that he had been in the dining room when R2 approached, yelled at him, and suddenly pushed him out of his wheelchair, and that there were no staff present and no staff witnessed the incident. R1 reported feeling bad that someone attacked him in his place of residence and said he asked a nurse to call the police, but the nurse refused. R1 denied pain and had no visible injuries or bruising. R1’s EMR showed diagnoses of paranoid schizophrenia and delusional disorder, and his abuse care plan, which identified him as at moderate risk for abuse due to psychiatric issues, included interventions such as observing him when in the company of peers and ensuring safety if he felt unsafe. The Social Services Director (V18) stated he was notified by the Administrator (V1) that there had been an altercation between R1 and R2 and that he and V1 reviewed dining room camera footage. The footage, later reviewed without audio, showed R2 pacing in the dining room, then approaching R1 in a threatening manner with repeated forward upper body movements, and then forcefully pushing R1 with two flat hands; the camera view of R1 was partially blocked and did not show whether he fell. V1 characterized the push as forceful and as abuse of R1. A nurse (V9) reported that R1 came down the hallway saying, “he hit me,” and that after assessing R1 and finding no injuries, she spoke with R2, who admitted, “He got in my face, and I pushed him out of my face,” while demonstrating a flat-handed pushing motion. V9 stated that once a resident says they pushed another resident, it is an abuse allegation that must be reported immediately. The facility’s Abuse and Retaliation Prevention and Reporting Policy affirmed residents’ right to be free from abuse and prohibited physical abuse, including hitting and controlling behavior through corporal punishment, yet the incident occurred in the dining room without staff supervision and resulted in resident-to-resident physical abuse.
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