Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident with a known history of assaultive behavior. Documentation in the medical record showed that one resident had multiple prior incidents of physically assaulting staff, including hitting, scratching, and beating staff members with objects. Despite these repeated behaviors, there was no consistent monitoring or behavioral intervention plan in place for this resident, except for a brief four-day period in March. Staff interviews confirmed that there was no ongoing order to monitor the resident's behavior, and monitoring was only done if an incident was observed and documented in a progress note. On one occasion, the resident with a history of assaultive behavior kicked another resident in the lower left leg while both were in the dining area. The assaulted resident had a moderate cognitive impairment, as indicated by a recent assessment. Staff were unaware of any prior incidents of this resident harming other residents before this event, and there was no evidence of proactive measures to prevent such incidents. The facility's policy committed to protecting residents from abuse by anyone, including other residents, but this was not effectively implemented in this case.