Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident hit them in the head. The incident occurred in the dining room when one resident, who had a history of verbal and physical behaviors and was care planned for altercations, approached another resident and took their milk. After a brief interaction where the first resident awoke and bumped the other's arm, the second resident poured milk on the first and then struck them in the head before staff could intervene. The dietary staff separated the residents and notified nursing staff, who assessed both residents and found no injuries. The resident who was struck had multiple diagnoses, including palliative care, lung cancer, dementia, chronic kidney disease, COPD, cellulitis, major depressive disorder, and anemia. This resident was assessed as having moderately impaired cognition but was able to communicate and had not displayed behavioral issues. The resident who initiated the altercation had diagnoses of dementia, psychosis, anemia, pain, malnutrition, heart disease, and osteoarthritis, with severely impaired cognition and a history of behavioral issues, including altercations with other residents. Their care plan included interventions to monitor and separate them from others during meals. Despite the incident, the facility did not implement increased monitoring or closer supervision for the resident who initiated the abuse until six days later, when they were moved to a secured memory care unit. The facility's abuse policy required increased supervision and protective measures for residents involved in such incidents, but these were not put in place immediately following the event.