Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse, resulting in actual harm. One resident with dementia and a history of wandering into other residents' rooms was repeatedly redirected by staff but continued to enter other rooms, including that of another resident with a known behavior problem involving hitting others. Despite care plans identifying these behaviors and interventions such as redirection and staff intervention, the measures in place were not effective in preventing the incident. On the day of the incident, a resident reported to an LPN that an assault was occurring. The LPN found the resident with dementia in another resident's room, bleeding from the face after being punched. The resident who committed the assault admitted to hitting the other resident due to frustration over repeated intrusions into his room. The injured resident required hospital treatment for facial bruising and a laceration above the left eye, which required sutures. Prior to the incident, the injured resident had no facial injuries. Both residents involved had documented behavioral issues and cognitive impairments, with care plans outlining interventions to address these risks. However, the interventions were not sufficient to prevent the assault. The facility did not implement additional interventions, such as a stop sign on the door, until after the incident had occurred. Observations after the incident revealed that the stop sign intervention was not consistently maintained.