Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent physical abuse between two residents, both of whom had diagnoses of dementia and compromised cognitive function. One resident, who had recently been admitted and assessed as having compromised mental status, exhibited exit-seeking and aggressive behaviors, including an incident where he attempted to choke a nurse. Despite these behaviors, the resident remained in the facility and was started on new medications following the initial aggression. The following day, the same resident became physically aggressive toward another resident, striking and scratching him in the face and neck area. The incident was not directly witnessed by staff, but was reported by the affected resident, who sustained abrasions and scratches. Both residents were separated after the incident, and assessments revealed injuries consistent with the reported altercation. The aggressive resident was unable to recall the event, and both residents had significant cognitive impairments that limited their ability to provide detailed accounts. Prior to the altercation, staff had observed the aggressive resident's exit-seeking and agitation, including a physical attack on a staff member. The facility's response to these behaviors included notifying the resident's power of attorney, consulting with a psychiatric nurse practitioner, and administering new medications. However, the resident remained in the facility and subsequently engaged in resident-to-resident physical abuse, resulting in injury.