Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of behavioral problems, including aggression and a moderate risk designation, physically struck another cognitively intact resident on the head following a verbal altercation. The incident took place in a common area near the nurse's station, where the aggressor, who has diagnoses including Schizoaffective Disorder, Bipolar Disorder, Major Depressive Disorder, and Dementia with Moderate Agitation, was involved in an argument over towels. Witnesses, including another resident and an LPN, confirmed that the aggressor became upset and hit the other resident after being confronted about his behavior. The facility's own policies require close supervision and more frequent observation for residents identified as moderate risk, particularly those with a history of aggression and behavioral issues. Documentation shows that the aggressor required attentive monitoring and periodic assessment to determine if the level of supervision was adequate. Despite these requirements, the physical altercation occurred, resulting in the cognitively intact resident being struck and calling for help, with staff responding after the incident had already taken place.