Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with severe cognitive impairment and multiple psychiatric and medical diagnoses was physically abused by another resident who was moderately cognitively impaired and had a history of behavioral problems, including verbal and physical aggression. The incident occurred in a hallway where the aggressor began punching the victim, resulting in skin discoloration to the victim's arms and upper body. Staff intervened to separate the residents, and the incident was reported to facility leadership and law enforcement. Review of the care plan for the resident with behavioral issues showed interventions were in place to protect others, such as removing the resident from situations and monitoring behaviors, but the altercation still occurred. Staff interviews confirmed that immediate action was taken to separate the residents and report the incident, but the event demonstrated a failure to fully protect residents from abuse as required by facility policy and resident rights.