Failure to Prevent and Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to prevent and protect cognitively impaired residents from physical abuse, resulting in two separate incidents involving four residents. In the first incident, a resident with severe cognitive impairment and a history of wandering entered another resident's room. The second resident, also severely cognitively impaired and with a documented history of agitation and aggression, pushed the wandering resident out of the room, causing the latter to fall and sustain a head injury. Staff did not witness the actual push, but a physical therapy assistant observed the aftermath, including the resident being shoved from the doorway and hitting his head. Documentation revealed that the injured resident had a history of Alzheimer's disease, dementia, and was at high risk for wandering, while the other resident had a history of behavioral disturbances and aggression. There was inconsistent staff awareness and documentation regarding the injury and the aggressive resident's history, and the incident was not substantiated as abuse by the facility administration due to both residents' cognitive impairments. In the second incident, two female residents with severe cognitive impairment and dementia were involved in a physical altercation. One resident was observed by staff grabbing her roommate by the hair and wrists, causing the roommate to feel angry and scared. The aggressor had a documented history of behavioral disturbances, including physical altercations and defensive behaviors when peers entered her space. Staff intervened promptly, separated the residents, and placed the aggressor on one-to-one supervision until she was transferred to the hospital for evaluation. The roommate was subsequently moved to another room and later to another unit at the request of her family. Both residents were assessed for injuries, and none were found, but the emotional impact on the victim was documented. In both cases, the facility's policies required prompt reporting, investigation, and protection of residents from abuse, including abuse by other residents. However, the facility did not identify or substantiate either incident as abuse, citing the residents' cognitive impairments and lack of willful intent. The documentation and staff interviews revealed gaps in monitoring, assessment, and recognition of aggressive behaviors and injuries, as well as inconsistent application of the facility's abuse prevention policies.