Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from resident-to-resident physical abuse. One resident with a history of dementia, mood disturbances, and anxiety was identified as being at moderate risk for abuse and neglect. The care plan for this resident included interventions to ensure safety and to report any incidents of abuse. Another resident, also with dementia and a history of agitation and aggressive behavior, was care planned for the potential to be physically and verbally aggressive due to poor impulse control and ineffective coping skills. On the date of the incident, staff responded to calls for help and found one resident standing over another, hitting him while he was in bed. Multiple staff members witnessed the altercation, and it was documented that the resident being attacked could not stand or transfer independently. The aggressor claimed that the other resident had pulled him out of bed, although staff verified this was not possible due to the victim's physical limitations. The incident was documented in progress notes and an initial abuse investigation report, and all required parties were notified.