Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with dementia and a history of physical aggression entered the room of another resident who was in bed and began to swat and hit him multiple times on the arm, side of the face, and head. The resident who was attacked had been calling out for staff assistance, as he sometimes does when he forgets to use the call light. The aggressor, who was severely cognitively impaired according to her most recent assessment, left the room after the incident, and staff responded after being alerted by the victim. The incident was documented in multiple records, including incident reports, nursing notes, and interviews with both the residents and staff. The victim reported being upset and in pain from the physical contact, though no visible injuries such as cuts were noted. Staff confirmed that physical contact was made and that the aggressor had a known potential for physical aggression related to her dementia and anxiety diagnoses. The facility's abuse prevention policy prohibits all forms of abuse, including resident-to-resident abuse, and requires staff to protect residents from such incidents. Despite this, the event occurred, indicating a failure to prevent abuse as required by policy. The aggressor's care plan had identified her risk for physical aggression, but the measures in place were insufficient to prevent her from entering another resident's room and causing harm.