Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
Facility staff failed to protect a resident's right to be free from physical abuse when a staff member witnessed another resident approach and strike the resident on the head twice—once with a closed fist and once with an open hand. The incident was unprovoked, and the victim did not initiate or provoke the aggression in any manner. The event occurred in a hallway near the nursing station, and was directly observed by a licensed nurse. Documentation in both residents' progress notes and the care plan confirmed the details of the altercation. The resident who was the victim had severe cognitive impairment, including diagnoses of anxiety disorder, dementia, and adult failure to thrive. The aggressor had a history of dementia and traumatic brain injury but was assessed as having intact cognition. Staff interviews confirmed the expectation that all residents should be free from abuse, and facility policies reviewed also emphasized the prohibition of abuse and the right of residents to be treated with respect and dignity.