Resident-to-resident altercation causing facial injuries on dementia unit
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident on a locked dementia unit. One resident with unspecified dementia without behaviors, auditory hallucinations, and a psychotic disorder with hallucinations wandered into another resident’s room. The other resident had unspecified dementia with agitation, anxiety, a psychotic mood disorder, and a documented history of physical behaviors one to three days per week, including hitting, kicking, pushing, scratching, and grabbing others. Both residents were not cognitively intact and had moderate mood issues. On the day of the incident, staff heard yelling from the aggressive resident’s room. An occupational therapy assistant entered and observed the aggressive resident kneeling over the wandering resident, with both residents on the floor and punching each other. The assistant called for help, and a CNA and an LPN responded and separated the residents. Blood was observed on both residents and on the floor. The aggressive resident later stated that a person had come into the room claiming money was owed, that he was confused, and that after being hit on the shoulder he “let him have it,” though he was later unable to recall the incident. Following the altercation, assessments and documentation showed the wandering resident had bruising and bleeding above and below the left eye, a laceration to the left eyebrow, a skin tear on the left thumb, and multiple facial contusions, and received pain medication. The aggressive resident had a small cut below the lip that did not require first aid. The facility’s abuse investigation noted that most of the incident was unwitnessed, that both residents resided on the locked dementia unit with dementia histories, and that the aggressive resident could not recall the event. The administrator later described the event as territorial in nature, related to the wandering behavior of one resident and the newness of the other resident to the unit, and stated he did not believe either resident meant to harm the other.
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.