Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
A resident with vascular dementia and peripheral vascular disease, who refused cognitive assessment, was subjected to abuse by another resident diagnosed with a femur fracture and Alzheimer's disease. The second resident, who had severe cognitive impairment and a history of physical and verbal behaviors, wandered into the first resident's room, demanded the resident leave their bed, and pinched the resident's wrist, resulting in two small bruises. The incident was substantiated as abuse by facility staff, and the affected resident expressed distress and requested to be kept away from the aggressor. Staff interviews confirmed that the aggressive resident was known to exhibit physical aggression and had previously scratched and hit staff members. At the time of the incident, there were no specific interventions in place, such as one-on-one supervision, to prevent the aggressive resident from interacting with other residents. Staff responded to the incident after it occurred, but prior to the event, monitoring and preventive measures were insufficient to protect the resident from abuse.