Failure to Prevent Resident-to-Resident Physical Abuse and Inadequate PASRR Utilization
Penalty
Summary
The deficiency involves the facility’s failure to prevent and protect a resident from resident‑to‑resident physical abuse. On the date of the incident, one resident (R9), who had a PASRR Level II indicating serious mental illness and a care plan noting risk for potential abuse due to behavior problems, poor impulse control, and poor boundaries, became involved in a verbal interaction with another resident (R13). A third resident (R8) exited his room and became involved in the exchange. According to the facility’s reported incident document, R8 became disrespectful in his choice of words and stepped in front of R9 as R9 turned to go back to his room. Staff were present and attempted to separate the two residents, but R9 reached around staff and pushed R8, causing R8 to stumble and fall. R8’s medical history included generalized epilepsy with status epilepticus, unsteadiness on feet, muscle wasting and atrophy at multiple sites, and other lack of coordination, placing him at higher risk for injury from a fall. Following the push, R8 was sent to the hospital, where records documented a small left posterior parietal scalp hematoma with scalp swelling. R9’s behavior note documented that he admitted shoving R8 after R8 threatened him. During a later interview, R9 stated that R8 “went crazy and touched” him, threatened to beat and kill him, and that he pushed R8 in response. Another resident (R13) recalled arguing with R9 and that R8 became involved, and reported that R9 later told him he had pushed R8, though R13 did not witness the actual push. Staff interviews revealed gaps in the facility’s processes related to abuse prevention and PASRR follow‑up. A CNA (V6) described that, when witnessing residents arguing or being triggered, he would separate them, notify the nurse and supervisors, redirect them, move them to a different location, and monitor them. The Administrator (V1), who witnessed the event, stated that she saw staff (a CNA) go over and separate the residents, and then saw R9 push R8 as the CNA turned away, characterizing the incident as an accident and stating she did not think it could have been prevented. The Social Service Director (V16), responsible for PASRR Level II follow‑up, stated he had not reviewed the PASRR Level I or II documents for either R8 or R9, despite the facility’s PASRR policy requiring review of PASRR documents to determine problems, needs, and issues to be addressed in care planning. The facility’s Abuse and Retaliation Prevention policy defined physical abuse as the infliction of injury on a resident by non‑accidental means requiring medical attention, including controlling behavior through corporal punishment, underscoring that the push and resulting injury met the facility’s own definition of physical abuse.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.