Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from abuse by another resident. One resident, who had a history of alcoholic cirrhosis, hepatic encephalopathy, diabetes, and PTSD, reported being hit in the arm and having a fork and knife thrown at her by another resident during lunch in the bistro area. The incident was witnessed by another resident and reported to staff, but there was no evidence of injury or pain upon assessment. The affected resident expressed feeling triggered due to a history of past abuse and reported ongoing distress following the incident. The resident who committed the act had severe cognitive impairment, as indicated by a BIMS score of 3, and a diagnosis of dementia. The care plan for this resident addressed cognitive impairment but did not include interventions related to behavioral issues or interactions with other residents. There was no documentation in the clinical record of the incident, nor evidence that the provider or family had been notified. Additionally, there was no follow-up or revision of the care plan to address the behavioral incident. Interviews with staff confirmed that the incident occurred and that the residents were separated afterward. However, the facility's documentation and response were incomplete, as there was no record of the incident in the perpetrator's clinical file, no notification to the provider or family, and no update to the care plan to address the behavioral risk. The facility's policy required protection from abuse and prompt investigation and reporting of such incidents, but these steps were not fully implemented in this case.