Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident with severe cognitive impairment from being physically abused by another resident, also with severe cognitive impairment. The incident took place in a dayroom where one resident, who had a history of agitation, aggression, and behavioral disturbances, told the other to move and then struck him in the right eye. The altercation was witnessed by an LPN, who intervened to separate the residents. The assaulted resident was found to have discoloration around the right eye, and during an interview, stated he was punched by someone he did not know for no reason. Prior to the incident, the resident who initiated the altercation had documented episodes of agitation, aggression, and other behavioral issues, with interventions such as emotional support and redirection being used. The care plan for this resident identified a risk for psychological and emotional distress following altercations, but the interventions in place did not prevent the physical abuse from occurring. Facility policies reviewed emphasized the right of residents to be free from abuse and the responsibility of staff to minimize the possibility of abuse, but these measures were not sufficient to prevent the incident.