Failure to Prevent Resident-to-Resident Abuse in Memory Care Unit
Penalty
Summary
The facility failed to protect two residents from abuse by another resident in the memory care unit. One resident, who had a history of severe cognitive impairment, physical aggression, and behavioral symptoms related to dementia and depression, slapped another resident in the face twice after an altercation over a napkin. On a separate occasion, the same resident grabbed a different resident's arm and slapped it multiple times while speaking to her. Both incidents involved physical contact initiated by the resident with a known history of aggression. The residents involved in the incidents all had severe cognitive impairment and resided in the memory care locked unit. The aggressor had a documented history of behavioral problems, including yelling, hitting, and using abusive language, and required varying levels of assistance with daily activities. The other two residents also had significant cognitive and physical impairments, with one being an elopement risk and the other on palliative care for end-stage Alzheimer's disease. At the time of the incidents, the aggressor was not consistently on 1:1 supervision, and the facility's care plan noted the potential for physical aggression but did not prevent the altercations from occurring. Staff interviews and record reviews confirmed that the aggressive resident had a pattern of physical outbursts and that staff were aware of her behavioral risks. Despite this knowledge, the facility did not prevent the incidents of abuse, and both affected residents were exposed to physical harm. The report notes that neither of the abused residents appeared to recall the incidents or showed signs of distress afterward, but the facility's failure to ensure their right to be free from abuse constituted a deficiency.