Failure to Prevent Multiple Resident-to-Resident Physical Altercations
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical abuse and resident-to-resident altercations. One resident with Klinefelter syndrome, intellectual disabilities, moderate cognitive impairment, and depression-related behavior problems reported that another cognitively intact resident with bipolar disorder and a history of aggression hit him on the right cheek and chest in the dining room. Documentation shows a new red area on his cheek, pain requiring Tylenol, and an undated statement in which he described being hit three times in the face and chest after taking back his candy. The facility’s report to the state agency notes there were no witnesses and that staff encouraged the two residents to remain in different areas of the dining room. Another incident involved two residents with dementia and bipolar or behavioral disturbances who engaged in a physical altercation in the dining room. One resident, who was moderately cognitively impaired and required partial assistance with mobility, reported that the other resident began yelling, talking badly to her, grabbed her arm, and tried to choke her before staff intervened. A CNA’s written statement and subsequent interview describe hearing yelling, then seeing one resident hitting with a fist and the other slapping, with both residents’ hands making contact. Progress notes and the facility’s report to the state agency document that both residents were yelling and slapping each other before staff could reach them. Additional altercations occurred involving residents with severe cognitive impairment and behavioral problems. In one case, a resident with vascular dementia and severe cognitive impairment struck another resident whose wheelchair had become entangled with his; staff statements and the facility’s report differ on whether the blow landed on the arm or face, but consistently describe the resident swinging his arm in agitation and making contact. In another case, a severely cognitively impaired resident with vascular dementia and potential for aggression was involved in a hallway altercation with a resident with dementia and behavioral disturbance; staff statements describe both residents yelling and hitting or slapping each other on the arms, chest, face, and hands before being separated. Across these events, residents with known behavior problems and aggression potential engaged in physical contact with one another, resulting in multiple instances of resident-to-resident physical abuse and altercations.
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