Resident-to-Resident Abuse During Dining
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from abuse by another resident when one resident threw an empty plastic bowl at another during a meal. Resident #1 was an 85-year-old female with dementia, reduced mobility, chronic pain, and multiple other medical conditions, and required setup assistance for all ADLs and was dependent for mobility. Her MDS indicated she was unable to complete the interview and had no documented physical or verbal behaviors. Her care plan identified her as at risk for impaired cognitive function/dementia and included interventions such as consistent routines, step-by-step instructions, and monitoring for changes in cognitive status. Resident #2 was a female with a history of nontraumatic intracerebral hemorrhage, hemiplegia/hemiparesis, schizoaffective disorder, bipolar disorder, generalized anxiety disorder, and other medical conditions. Her MDS showed a BIMS score of 12 (moderate cognitive impairment), dependence or need for setup with all ADLs, and no documented physical or verbal behaviors. Her care plan identified risk for impaired cognitive function related to CVA, schizophrenia, and bipolar disorder, and a potential for mood problems related to schizophrenia and bipolar disorder, with interventions focused on communication, psychosocial support, and monitoring mood and cognitive changes. On the morning of 03/03/26 during dining, Resident #2 threw an empty plastic cup/bowl at Resident #1, striking Resident #1 on the upper body/shoulder after Resident #1 reportedly reached for or attempted to take food from Resident #2’s tray and coughed over her food. Staff interviews indicated that Resident #2 told staff she threw the cup because Resident #1 tried to take food from her tray and did not stop when told to. The nurse’s progress note documented a resident-to-resident incident in which Resident #1 was struck by a cup thrown by Resident #2, with no injuries or distress observed and Resident #1 denying pain. The facility’s policy stated that each resident has the right to be free from abuse, neglect, exploitation, and mistreatment by anyone, including other residents. Despite this policy, the incident occurred, and the facility failed to ensure Resident #1 was free from abuse by Resident #2.
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