Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by other residents, resulting in substantiated incidents of abuse. In the first incident, a resident with severe dementia, who had a history of reaching out and grabbing people, was seated in his doorway when another resident walked by. The seated resident grabbed the passing resident's wrist and did not let go when asked. In response, the passing resident grabbed the seated resident by the back of the neck and shook him. This action was witnessed by the staffing coordinator, who immediately intervened. The investigation determined that the action was willful and constituted physical abuse. The resident who was the victim in this incident had diagnoses of dementia and Alzheimer's disease, with significant cognitive and memory impairments, and a history of involvement in physical altercations. The assailant had Parkinson's disease and moderate cognitive impairment, with a documented history of verbally and physically aggressive behavior toward others. Both residents had care plans addressing their behavioral issues, but the incident still occurred, indicating a failure to prevent abuse. In the second incident, two residents began arguing loudly in a common room. One resident, who had moderate cognitive impairment and a history of verbal aggression, attempted to push the other's wheelchair but instead pushed the resident directly, causing him to fall and sustain two skin tears and later bruising. Staff separated the residents and provided first aid. The investigation substantiated that the physical abuse was willful. The victim in this case had moderate cognitive impairment and required assistance with daily activities, while the assailant had dementia with behavioral disturbances and required substantial assistance with care.