Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse by another resident, contrary to its Abuse Prevention and Reporting policy that affirms residents’ right to be free from abuse and prohibits physical abuse such as hitting and pushing. According to the Abuse Investigation Checklist, an allegation of physical abuse occurred when two residents were in the hallway and one resident (R2) reached out with a flat hand and pushed the other resident (R1) in the chest. A housekeeper (V6) witnessed the altercation, observed the push, and heard R1 yell, “Ouch, he pushed me.” R1 later stated that he and R2 had been talking in the hallway when R2 pushed him in the chest with his hand. R1’s MDS documents that he is cognitively intact. A second incident of physical abuse between the same two residents was documented when a CNA (V7) observed R2 strike R1 on the right forearm while R2’s wheelchair was in the hallway. R1 reported that R2’s wheelchair had become caught on a piece of equipment and that when he attempted to assist by moving the wheelchair, R2 struck him on the right forearm. R2’s MDS documents moderate cognitive impairment with fluctuating disorganized thinking, and R2’s care plan identifies mood disturbances related to dementia and directs staff to monitor and report indicators that R2 may be at risk of harming others, such as increased anger, agitation, or feelings of being threatened. The Administrator (V1) and DON (V2) confirmed both incidents and stated that R1 sometimes enters R2’s personal space, which R2 dislikes and sometimes responds to with physical behaviors.
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