Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A resident with diagnoses including bipolar disorder, dementia, Parkinson's disease, and schizoaffective disorder exhibited physical aggression towards another resident. The care plan for this resident identified a history of wandering, refusing care, and both verbal and physical aggression, with interventions such as medication administration, positive approaches to care, and seeking additional staff assistance as needed. Despite these measures, the resident physically assaulted another resident on two occasions, first by striking her with a closed fist and then by slapping her and pulling her hair. Both incidents occurred in a common area when the residents' wheelchairs became entangled, and staff intervened to separate them without reported injury. The facility's policy prohibits all forms of abuse, including physical abuse such as hitting and slapping. Documentation showed that the aggressive resident was already on hourly checks due to elopement risk, and the other resident was also monitored hourly for safety following the incidents. The events were confirmed through medical record review, facility-reported incident documentation, and staff interviews, establishing that the facility failed to ensure residents remained free from abuse by not preventing the physical altercations.