Failure to Protect Residents from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect two residents on the Memory Care Unit from physical abuse by another resident. One resident, who had moderate cognitive loss and a history of verbal and physical behaviors, became increasingly agitated and aggressive over a period of weeks. This resident pulled another resident's hair and later struck a different resident, who was also the spouse, with a full water pitcher, causing physical injury and mental distress. Staff interviews and medical record reviews confirmed that the aggressive resident had exhibited escalating behaviors, including yelling at staff, throwing objects, and physical altercations with other residents. The first incident occurred when a resident with extensive cognitive loss and no prior behavioral issues was walking out of the dining room and interacted with the aggressive resident's spouse. The aggressive resident responded by yanking the other resident's hair and pulling them down. The second incident involved the aggressive resident entering the spouse's room and striking them in the head with a water pitcher, resulting in abrasions and redness. Staff members heard distress sounds and intervened, but not before the aggressive resident made contact multiple times. The spouse was found in a defensive posture, and the aggressive resident was removed from the room. Medical records and staff interviews indicated that the aggressive resident had a documented history of behavioral problems, including physical aggression toward staff and other residents, and had been seen by psychiatric professionals for increased agitation. Despite these known risks, the resident was able to access and harm other residents on multiple occasions. The facility's failure to prevent these incidents resulted in physical and psychological harm to the affected residents.