Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A resident with severe cognitive impairment, dementia, anxiety, and depression exhibited ongoing behavioral issues, including yelling, aggression, and physical threats toward others. Despite being care planned for these behaviors, the resident continued to display escalating aggression, such as yelling at staff, attempting to throw a walker, and threatening other residents. On one occasion, the resident verbally threatened another resident in the hallway and, shortly after, physically struck that resident on the arm, leaving a visible red mark. The incident was witnessed by staff, who observed the aggressor approaching the other resident, raising a hand, and making physical contact. The resident who was struck also had severe cognitive impairment and was able to defend themselves during the altercation. Both residents had documented histories of cognitive decline and behavioral challenges, with the aggressor's care plan specifically noting the need for staff intervention to protect the rights of others. Facility policies required that all resident-to-resident altercations, including those resulting in physical injury or pain, be investigated and reported. The event was investigated, and staff interviews confirmed awareness of the altercation and the facility's responsibility to protect residents from abuse. The deficiency occurred when the facility failed to prevent one resident from physically abusing another, resulting in harm.