Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent one resident from physically abusing another resident. One resident with severe cognitive impairment and a history of psychiatric and behavioral diagnoses, including schizoaffective disorder and traumatic brain injury, exhibited physical and verbal aggression. On the day of the incident, this resident became aggressive with staff and attempted to hit them while trying to leave, ultimately requiring intervention by three staff members and the police. During this episode, the resident physically assaulted another resident by grabbing the individual's leg and pulling them to the ground. Prior to this event, the resident's care plan and assessments did not document any physical behaviors or incidents involving aggression toward other residents. The resident who was assaulted also had severe cognitive impairment and multiple psychiatric and medical diagnoses, including dementia with agitation and psychosis. At the time of the incident, this resident was attempting to ambulate in a common area when the aggressor pulled him down, resulting in a fall to his knees. Staff immediately separated the residents and assessed the assaulted resident for injuries, finding none. The facility's investigation substantiated that resident-to-resident abuse had occurred. Policy reviews confirmed that the facility was required to prevent all forms of abuse, including those perpetrated by other residents.