Failure to Prevent Resident-to-Resident Physical Abuse Among Cognitively Impaired Residents
Penalty
Summary
The facility failed to protect four cognitively impaired residents from abuse, specifically failing to prevent resident-to-resident physical abuse. Two separate incidents occurred involving residents with severe cognitive impairment and documented behavioral issues. In the first incident, one resident with a history of aggressive and combative behavior placed both hands around another resident's neck and forcefully squeezed, requiring staff intervention to separate them. The aggressor had a documented pattern of aggression towards staff and peers, including previous episodes of hitting, scratching, and resisting care. Both residents involved were unable to recall the incident due to their cognitive status. In the second incident, another resident with dementia and a history of behavioral problems struck a peer in the face with a closed fist. The aggressor was observed by staff walking quickly toward the victim, calling her by an incorrect name, and then hitting her. The victim complained of pain and had visible redness on her face. Both residents involved in this incident were also severely cognitively impaired and unable to recall the event during subsequent assessments. Staff interviews and record reviews revealed that both aggressors had known histories of aggression and behavioral disturbances, including prior physical altercations and resistance to care. Despite these known risks, the facility did not implement effective interventions to prevent these incidents. The facility's abuse policy affirms residents' rights to be free from abuse and outlines the responsibility to prevent such occurrences, yet the events described demonstrate a failure to uphold these protections for the residents involved.