Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving one resident who was struck in the face by another resident. The incident occurred when one resident, who has a history of inappropriate contact, physical aggression, and paranoia, reacted aggressively after another resident attempted to open his door to assist him. The aggressor, who is cognitively intact but has multiple psychiatric diagnoses including Alzheimer's Disease, psychosis, and obsessive-compulsive disorder, became agitated and hit the other resident, resulting in redness to the face and arm, as well as bleeding from the head. The affected resident, who is also cognitively intact and has diagnoses including cerebral infarction and Alzheimer's Disease, reported feeling fearful of the aggressor and stated he does not feel safe around him, although he generally feels safe in the facility when staff are present. Prior to the incident, the aggressor's care plan documented a history of physical aggression, poor impulse control, and a dislike of having his personal space invaded. The care plan also noted previous encounters with other residents and interventions such as 15-minute checks. Despite these documented risks and behaviors, the incident occurred when the other resident, unaware of the behavioral symptoms, attempted to help by opening the door, which triggered the aggressive response. The facility's abuse prevention policy states that residents must not be subjected to abuse by anyone, including other residents, and defines resident-to-resident abuse as willful, deliberate actions.