Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in a physical altercation. One resident, who had a history of moderate cognitive impairment, dementia, and muscle weakness, was struck twice on the head by another resident with severe cognitive impairment, behavioral symptoms, and a history of aggression. The incident occurred in the dining room as the aggressive resident was being escorted in a wheelchair and began swinging her arms, making contact with the other resident. The assaulted resident initially denied being hit but later admitted to the incident during the investigation, stating he did not want to report it due to fear of escalation and concerns about his probation status. The aggressive resident had documented behavioral issues, including hallucinations, delusions, and a pattern of physical and verbal aggression toward others. She was already on one-to-one monitoring and awaiting transfer to a psychiatric hospital due to her escalating behaviors. Despite these interventions, the resident was able to physically assault another resident. Staff present during the incident did not immediately report the event, and the facility's investigation was only initiated after a witness reported the incident two days later. No injuries were found on assessment, but the delay in reporting and investigation was evident. The facility's policies required prevention, investigation, and reporting of abuse, neglect, and exploitation. However, the incident was not reported to law enforcement as required by policy, and there was a lack of immediate documentation and witness statements. The failure to promptly identify, report, and investigate the abuse incident, as well as to protect the resident from ongoing verbal abuse, constituted a deficiency in ensuring residents' rights to be free from abuse and neglect.