Failure to Prevent Resident-on-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. Resident 2, who had epilepsy, depression, muscle weakness, unsteadiness on feet, and a traumatic brain injury, and who was assessed with a BIMS score of 7 indicating severe cognitive impairment, was sharing a room with Resident 1. Staff were aware that Resident 1 could become easily agitated, upset, and rude, and that the two residents had a history of disagreements and arguments about lights and television volume at night. These prior conflicts were not documented or reported in the medical record, and no behavior concerns for Resident 1 were care planned or communicated to leadership. On the day of the incident, CNA 1 was preparing Resident 2 for a shower when Resident 1 began yelling at Resident 2. CNA 1 moved Resident 2 into the hallway to prevent escalation and notified Resident 1’s nurse that Resident 1 was upset and yelling, and that the residents should be separated. CNA 1 then escorted Resident 2 to the shower and returned with him about 15 minutes later. She positioned Resident 2 in his wheelchair in front of his bed toward the back of the room, with his back to the door and to Resident 1’s bed, while she stood along the back wall at Resident 2’s nightstand. While CNA 1 was at the nightstand, she observed Resident 1 get up from his bed, approach Resident 2 from behind, and hit him in the back of the head with a fist. CNA 1 called for help, and staff responded and separated the residents. LN 1 arrived and saw Resident 1 standing between the two beds; both residents were yelling, and Resident 2 reported he had been “sucker punched” in the back of the head and was upset. LN 2, the nurse assigned to both residents that day, later assessed Resident 2 for injuries; Resident 2 stated that Resident 1 came over and hit him in the back of the head and appeared surprised, scared, and startled. The DON and Social Services Director confirmed there was no documentation of prior disagreements or behavior issues in either resident’s record, despite staff knowledge of previous arguments and Resident 1’s tendency to become easily agitated.
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