Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A resident (R1) with a history of cognitive communication deficit, major depressive disorder, type 2 diabetes with polyneuropathy, and lack of coordination was physically struck in the face and legs by another resident (R2). R2 had a documented history of unspecified dementia, psychotic and mood disturbances, and was previously identified as having the potential for physical and verbal aggression, with interventions noted in the care plan to address these behaviors. On the day of the incident, a CNA (V3) witnessed R2 hit R1 in the face, separated the residents, and after assisting another resident, returned to see R2 strike R1 again. R1 reported not being injured during the incident. The facility's abuse prevention policy requires identification of residents at risk for abuse and implementation of care plan interventions to reduce such risks. Despite this, R2, who had a known history of aggression and a prior incident of striking another resident at a previous facility, was able to physically abuse R1 on two occasions during the same event. The administrator was unaware of the second strike and of R2's prior aggressive behavior at another facility. The incident was reported to the police, and witness statements were collected, but the report does not mention any corrective actions taken following the event.