Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A resident with major depressive disorder and dementia was physically abused by another resident who had a documented history of aggressive behaviors, including previous incidents of hitting other residents and staff. The aggressor, who also had dementia, depression, and schizophrenia, had a BIMS score indicating moderate cognitive impairment and was known to display both physical and verbal behavioral symptoms toward others. Despite these known risks and previous similar incidents, the resident was able to strike another resident on the head with a hard plastic coffee cup, causing the cup to shatter and resulting in a laceration that required hospital evaluation and treatment. Multiple staff members, including CNAs and a nurse, witnessed the incident and confirmed that the attack was unprovoked and occurred while both residents were seated near the nurse's station. Staff reported that the aggressor had previously broken a coffee cup on another resident's head, and a CNA was assigned to monitor the resident due to these prior behaviors. However, the monitoring was insufficient to prevent the incident, and the aggressor was able to inflict harm before staff could intervene. The facility's own policy prohibits any form of resident abuse and requires systems for prevention, yet the repeated nature of the aggressor's behavior and the failure to prevent this latest incident demonstrate a breakdown in protective measures. The injured resident sustained a head wound with moderate bleeding and was sent to the emergency department for further evaluation, while the aggressor continued to display aggressive behavior even after the incident.