Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident with dementia from physical abuse by another cognitively intact resident. The incident occurred when the resident with dementia repeatedly went through the belongings of the other resident, despite being asked to stop. The cognitively intact resident, after reporting the behavior to staff and receiving no intervention, pushed the resident with dementia against a wall, leading to a physical altercation where both residents sustained minor head lacerations. Staff were not present during the altercation and only became aware after the incident was reported by the involved resident. Interviews and record reviews revealed that the resident with dementia had a history of wandering and entering other residents' rooms due to severe cognitive impairment, as documented in care plans and assessments. The cognitively intact resident had no prior history of aggression and was assessed as having minimal risk for aggressive behavior. Despite repeated complaints to staff about the ongoing behavior, no preventative measures were implemented to address the situation or protect the residents involved. The facility's abuse prevention policy affirms the right of residents to be free from abuse and requires the prevention of mistreatment and neglect. However, the facility did not follow its own policy, as staff failed to intervene or implement strategies to prevent the altercation, resulting in substantiated physical abuse. Both residents required medical evaluation for their injuries, and the incident was confirmed as abuse by facility leadership.