Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse when one resident physically assaulted another. Resident 10, who had a history of stroke, dysphagia, and documented behavioral issues including verbal and physical aggression, threw a beverage bottle at Resident 11, striking them in the face and causing a small cut on the bridge of the nose. At the time of the incident, all staff were reported to be in resident rooms providing care to other residents, leaving the area unsupervised. Resident 10's care plan included interventions such as providing distractions and monitoring the resident at all times during meals due to their aggressive behaviors, but these interventions were not effectively implemented at the time of the incident. Resident 11, who had no cognitive impairment or behavioral issues, was injured as a result of the altercation. Staff interviews confirmed that Resident 10 had a pattern of aggressive behavior, including previous altercations with Resident 11 and other residents, as well as incidents of physical aggression toward staff. Documentation showed that Resident 10 had initiated several incidents with other residents and staff in the months leading up to the event, but no physical harm had been documented until this incident. The facility's failure to adequately supervise and implement care plan interventions for Resident 10 resulted in harm to Resident 11.