Failure to Protect Resident from Physical Abuse in Rehabilitation Room
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident, who had a history of behavioral outbursts related to Huntington's Disease, threw a walker and struck the resident on the left knee in the rehabilitation room. Both residents involved were cognitively intact according to their most recent assessments. The incident was witnessed by the Director of Rehab and a Physical Therapy Assistant, who confirmed that the action was unprovoked and that other residents were present during the event. After the initial assault, the aggressor attempted to attack the same resident again and was restrained by staff. Despite the aggressor's known history of throwing objects and a physician's order to monitor and document such behaviors, the facility did not classify the event as resident-to-resident abuse, instead treating it as a behavioral outburst. The Director of Nursing and other staff interviews revealed that the incident was not reported to the Department as abuse, and the facility's policy on abuse prevention, which mandates protection from all forms of abuse, was not followed in this case.