Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
A resident with severe cognitive impairment and a history of encephalopathy, altered mental status, and cognitive communication deficit was involved in an incident where he was pushed to the floor by another resident. The resident who was pushed was known to wander into other residents' rooms due to his cognitive deficits and occasional incontinence, sometimes forgetting where the bathroom was. On the day of the incident, he entered another resident's room while looking for the bathroom. The resident who pushed him had diagnoses including Alzheimer's disease, traumatic brain injury, adjustment disorder, and intellectual disabilities, and was documented as being at risk for abuse and displaying behaviors such as agitation and aggression. On the day of the incident, a witness observed the cognitively intact resident push the cognitively impaired resident, causing him to fall to the floor. The incident was reported by a staff member who witnessed the event, and the resident who was pushed was assessed with no injuries noted at the time. Prior to the incident, the resident who pushed had exhibited agitation and verbal aggression, and the resident who was pushed had a care plan identifying his risk for abuse and neglect. Despite these known risks and behavioral histories, the facility failed to prevent the abusive interaction between the two residents, resulting in one resident being pushed to the floor by another.