Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from physical abuse by another resident. The incident involved a resident with a history of encephalopathy, bipolar II disorder, schizoaffective disorder, and anxiety disorder, who was at risk for aggression and behavioral symptoms, including wandering and verbal aggression. The care plan for this resident included interventions to avoid confrontation and to intervene as necessary to protect the safety of others. Despite these measures, the resident was physically assaulted by another resident who struck them multiple times in the face. The resident who committed the assault had diagnoses of generalized anxiety disorder, major depressive disorder, and dementia, and was noted to have impaired thought processes and mood disturbances with agitation. Prior to the incident, this resident had exhibited aggressive and hostile behaviors, including yelling, using profanity, and threatening others. Behavior monitoring and increased assessment were implemented, but staff were unable to redirect the resident effectively during behavioral crises. On the day of the incident, the resident admitted to hitting the other resident after a confrontation in the smoking area. Interviews with staff and other residents revealed that the aggressor had a history of targeting the victim and had previously intervened in altercations involving the victim and other residents. Staff were aware of the behavioral issues and previous incidents but did not anticipate the physical altercation. The facility's abuse and neglect policy required identification and intervention for residents at risk of abuse or with behaviors that could lead to conflict, but these measures were insufficient to prevent the incident.