Failure to Prevent Resident-to-Resident Physical Assault
Penalty
Summary
The facility failed to prevent a resident-to-resident physical assault involving a resident with Alzheimer's dementia and severe cognitive impairment and another resident with Paranoid Schizophrenia and moderate cognitive impairment. The incident occurred when one resident, who has a history of aggressive behavior and communication difficulties due to language barriers, became agitated and struck another resident in the dining room. Staff were present and intervened to separate the residents, but the assault had already occurred. The resident who was struck did not exhibit a reaction and was assessed with no injuries found. Prior to the incident, there were multiple documented episodes of the aggressive resident displaying escalating behaviors, including yelling, cursing, and attempts to strike other residents. Staff had to intervene on several occasions to prevent altercations. The care plan for the aggressive resident identified risks for verbal and physical aggression but did not address his communication or language needs, despite staff observations that language barriers contributed to his frustration. Both residents involved were assessed as being at moderate risk for mistreatment.