Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident was not protected from physical abuse by another resident with a known history of aggressive behaviors. The incident took place in the dining room, where one resident, whose electric wheelchair battery had died, was unable to move, blocking the path of another resident. The second resident became irritated and, after a verbal altercation, struck the first resident in the face, knocking off his glasses and causing a scratch near his nose. A dietary employee witnessed the altercation and reported that only the second resident struck the first, with no evidence that the first resident attempted to hit back. The facility's investigation included statements from both residents and staff. The resident who was struck had significant medical conditions, including hemiplegia, aphasia, Alzheimer's disease, dementia, bipolar disorder, and a history of brain injury, and was dependent on a wheelchair. Despite these vulnerabilities, the resident was left in a situation where he was exposed to potential harm from another resident known to have behavioral issues. The second resident, who struck the first, had diagnoses including paraplegia, psychosis, anxiety disorder, depression, and a documented history of physical aggression and prior altercations with other residents. The facility's abuse policy prohibited physical abuse and required individualized care plans for residents identified as potentially abusive. However, the care plan for the aggressive resident only included general interventions such as reminders about unacceptable behavior and ensuring basic needs were met. The incident was initially unsubstantiated by the facility's prior administrator, who concluded there was no willful intent to harm, despite witness statements and the facility's own policy defining physical abuse as the willful infliction of injury through deliberate acts such as hitting.