Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from abuse when one resident physically struck another in the head. Specifically, a male resident with a history of dementia, Alzheimer's disease, and behavioral problems, including physical aggression, was hit in the head by a female resident diagnosed with bipolar disorder, schizophrenia, and poor impulse control. The incident occurred in the day room when the male resident reportedly ran over the female resident's foot with his wheelchair, prompting her to hit him in the head. This event was witnessed by a CNA, who heard the altercation and observed the physical contact. Record reviews indicated that the male resident had documented short- and long-term memory problems and a history of behavioral issues, while the female resident had a care plan addressing her potential for physical behaviors and poor impulse control. The care plan for the female resident included interventions for immediate staff intervention in the event of physical behaviors toward others. Despite these documented risks and interventions, the physical altercation occurred, and staff intervention only took place after the incident had already happened. Interviews with staff and residents confirmed the occurrence of the incident, with the CNA stating she intervened immediately after hearing the altercation and witnessing the physical contact. The facility's policy states that residents have the right to be free from abuse, including abuse by other residents. However, the incident demonstrated a failure to prevent resident-to-resident abuse as required by facility policy and regulatory standards.