Resident Not Protected from Physical Abuse by Visitor
Penalty
Summary
A resident with a diagnosis of alcohol-induced psychotic disorder and intact cognition was involved in an altercation with a visitor, during which the visitor pushed the resident. Prior to the incident, the resident had exhibited verbal and physical aggression toward both visitors and staff, as documented in the SBAR communication tool. Despite this history, there was no documented evidence of a person-centered care plan addressing the resident's potential risk of aggression. The incident was witnessed by a licensed nurse, and the facility's policy states that residents must be free from abuse by anyone, including visitors. The failure to implement appropriate care planning and protective measures resulted in the resident not being protected from physical abuse by a visitor.