Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from physical abuse by another resident. The incident involved a female resident with severe cognitive impairment, legal blindness, and altered mental status, who was rarely or never understood and had a BIMS score of 00. This resident was sitting in her wheelchair in the hallway when another resident, who had a moderate intellectual disability, generalized anxiety disorder, and a history of behavioral issues, approached and kicked her on the left leg below the knee. The event was witnessed by a CNA, and the resident who was kicked was assessed immediately after the incident, with no apparent injury or pain noted at that time. The resident who committed the act had a documented history of poor impulse control, episodes of agitation, and previous incidents of hitting other residents. Staff interviews confirmed that this resident was known to be bossy, argumentative, and had difficulty regulating emotions and behaviors. The care plan for this resident included interventions for behavioral symptoms, such as calmly redirecting inappropriate behavior and providing supervision. Despite these interventions, the resident was able to approach and physically abuse another resident in a common area. Prior to the incident, staff were aware of the behavioral risks associated with the resident who committed the abuse, including a previous similar incident earlier in the year. The facility's failure to prevent this altercation, despite knowledge of the resident's behavioral history and the vulnerability of the other resident, led to the deficiency. The incident was observed, documented, and reported by staff, and the residents involved were assessed following the event.