Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in a physical altercation. One resident with a history of dementia, altered mental status, and documented aggressive and combative behaviors, including hallucinations and delusions, approached another resident who was sitting at the end of a hallway. The aggressive resident called the other resident derogatory names and physically struck her multiple times. Nursing notes and staff interviews confirmed that the aggressor had a pattern of combative behavior, including previous threats and physical aggression toward staff and other residents. The resident who was struck had diagnoses of dementia, bipolar disorder, major depressive disorder, and anxiety disorder, with mild cognitive impairment noted on assessment. After the incident, nursing documentation and a wound nurse assessment confirmed the presence of a bruise on the resident's thigh, which was attributed to the physical contact. Despite these clinical findings, the facility's investigation report concluded that the incident was unsubstantiated for injury, even though multiple nursing notes documented the bruise. Staff interviews revealed that the incident was reported and the residents were separated, with the aggressor being moved to another room and monitored. However, the facility's documentation did not reflect adequate follow-up or acknowledgment of the injury sustained by the resident who was struck. The facility's policy states that residents have the right to be free from abuse, but the actions and documentation in this case did not ensure that right was upheld.