Failure to Prevent Resident-to-Resident Abuse and Ensure Resident Safety
Penalty
Summary
A deficiency occurred when a resident with no cognitive impairment was physically struck on the arm by another resident who had significant mental and cognitive impairment and a documented history of aggressive behaviors and resident-to-resident altercations. The incident took place in the resident's shared room, where a CNA witnessed the aggressor sitting on the victim's bed and attempting to make physical contact. The CNA intervened immediately, and the resident was assessed with no visible injuries. However, the victim expressed fear and concern for her safety following the incident. Despite being moved to a different room on a separate unit, the victim reported that the aggressor entered her new room on multiple occasions after the initial altercation. This ongoing access caused the victim to feel unsafe, leading her to request that her door be kept closed and to express fear that the aggressor would find her again. The victim became too fearful to leave her room or participate in activities, and staff interviews confirmed that the aggressor had further contact with the victim after the incident. Interviews with facility staff, including the Social Services Director and the DON, revealed that there was a lack of increased supervision and separation between the two residents following the altercation. Staff acknowledged that the abuser should have been separated from the victim to prevent further emotional distress and that residents have the right to feel safe. The facility's policy also required protection of residents from further harm during investigations, which was not fully implemented in this case.