Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The deficiency involves the facility’s failure to protect two residents from physical abuse during an unwitnessed altercation. One resident with chronic pulmonary edema, end stage renal disease, congestive heart failure, chronic kidney disease, ADL self-care deficits, limitations in physical mobility, and moderate cognitive impairment reported that another resident entered the room via the shared bathroom and physically assaulted them. The resident stated that the other resident hit them an unknown number of times, including kicking the dialysis port and scratching the face, leading to significant pain and a request for hospital evaluation. The other resident involved had a history of CVA with hemiplegia, idiopathic peripheral autonomic neuropathy, congestive heart failure, muscle wasting and atrophy, and major depressive disorder, and was care planned as having potential for verbal and physical aggression. This resident initially wrote that the first resident entered their room through the bathroom and took cigarettes, prompting them to stand up and chase the first resident back to their room, where the first resident allegedly threw a walker, causing a fall. In a later interview, this resident admitted to punching the other resident three times because of the alleged theft of cigarettes, and reported losing balance and falling, resulting in right hip pain for about a day. Clinical documentation and hospital records confirmed injuries to the first resident, including a chest wall contusion and facial abrasion attributed to a physical assault, with pain levels documented as high as 8–9 out of 10 on subsequent shifts and treatment with oxycodone. A skin assessment noted a scratch with scab near the right nostril. The second resident reported right hip pain after the fall. Staff interviews confirmed that the incident was considered abuse, that it was unwitnessed and over before staff entered the room, and that the residents had engaged in a physical altercation resulting in injuries to both, demonstrating that the facility did not prevent resident-to-resident physical abuse as required by its abuse, neglect, and exploitation policy.
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