Failure to Protect Resident from Physical Abuse During Resident-to-Resident Altercation
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple psychiatric diagnoses was not protected from physical abuse by another resident. The incident involved one resident standing in the doorway to their room when another resident, also with severe cognitive impairment and a history of physical aggression, attempted to enter the room and slapped the first resident on the cheek. The altercation was witnessed by the Recreation Director, who observed the aggressor attempting to enter the room and the subsequent slap, but did not intervene at the time as she was down the hall. The affected resident was noted to be upset and crying after the incident, though no physical marks were observed. The resident who committed the abuse had documented interventions in their care plan to address potential physical aggression, including early intervention when agitated and guidance away from sources of distress. Despite these interventions, the aggressive behavior was not prevented, and the incident occurred in a common area where staff were present but unable to intervene in time. Facility documentation and interviews confirmed that the facility failed to ensure the resident was free from physical abuse, as required by policy.