Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with a history of inappropriate behaviors, including psychosis and mood disorder, struck another resident on the head with a therapy device. The incident took place in a hallway and was witnessed by a certified nurse aide, who reported that the aggressor was upset because the other resident, who had severe cognitive impairment and a history of wandering, had entered their room by mistake. The aggressor verbally expressed frustration before using a flexi-bar to hit the other resident from behind. The resident who was struck had significant cognitive impairment, exhibited wandering behaviors, and required supervision as documented in their care plan. Despite interventions such as frequent checks and redirection, the resident was able to enter another resident's room, which led to the altercation. The staff present intervened immediately after the incident, but the event still resulted in one resident physically striking another. The facility's investigation concluded that no abuse had occurred, citing the aggressor's psychiatric issues and lack of intent to harm, as well as the absence of injury to the resident who was struck. However, the incident itself demonstrated a failure to protect a resident from physical abuse, as required by regulation, and highlighted lapses in supervision and monitoring of residents with known behavioral risks.