Resident-to-resident physical abuse during altercation over walker
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse when one resident struck another. According to the facility’s preliminary and final abuse investigation reports, a cognitively severely impaired resident with Alzheimer’s disease, anxiety disorder, restlessness, and agitation approached another cognitively severely impaired resident who requires a walker for ambulation while the second resident was seated at a table sipping a drink. The first resident attempted to take the second resident’s personal walker, and when the second resident refused to relinquish it, the first resident slapped the second resident on the back with an open hand. Witness statements from an LPN, an activity aide, and a CNA consistently described the first resident trying to take the walker, the second resident holding onto it, and the first resident then smacking the second resident on the back. The records show that both residents had prior care plans addressing physical and verbal behaviors toward staff and peers, and both had BIMS scores of three, indicating they were cognitively severely impaired. The MDS for the first resident documented independence in walking and the presence of physical and verbal behaviors, while the MDS for the second resident documented the need for a walker to assist with walking. During the incident, when staff intervened to separate the residents, the second resident attempted to retaliate and instead struck the LPN in the mouth, and the first resident became unsteady, lost balance, and fell, hitting their head on a table leg. The facility’s abuse prevention policy affirms residents’ rights to be free from abuse and states that the facility prohibits abuse and is responsible for preventing occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services, and mistreatment of residents.
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