Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with a history of dementia, aggressive behavior, and other psychiatric and mobility issues (R2) physically abused another resident (R1) in the dining room. R2, whose care plan noted a risk for psychosocial problems, physical aggression, and behavioral outbursts, became agitated when attempting to maneuver his wheelchair through a crowded area. After R1 suggested an alternative route, R2 began yelling and kicked R1 several times in the knees, causing pain due to R1's pre-existing knee problems. Staff were alerted by the commotion and separated the residents, but the incident was not followed up with an assessment of R1's injuries or further communication with R1 regarding the event. The facility's Abuse Prevention Program Policy requires immediate protection of residents involved in abuse, prompt investigation, and ongoing monitoring of residents with increased vulnerability. Despite these policies, R1 reported that no one followed up to check on her or her injuries after the incident, and there was no documentation of an assessment or intervention for R1 post-incident. The event was reported to the state agency, but the lack of immediate and appropriate response to R1's needs following the altercation constituted a failure to protect the resident from abuse as required by facility policy.