Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from abuse by another resident with a history of aggressive behaviors. According to the facility's abuse policy, staff were required to monitor, assess, and implement care planning interventions for residents with behaviors that could lead to conflict or harm. Resident 2, who had diagnoses including dementia, anxiety, and depression, exhibited multiple behavioral issues such as agitation, paranoia, and hostility, and was to be closely monitored and redirected as needed. Despite these interventions being outlined in the care plan, Resident 2 was able to push another resident, resulting in harm. On the day of the incident, Resident 3, who was also cognitively impaired and had a history of behavioral issues, approached Resident 2 and tapped him on the shoulder. Resident 2 responded by forcefully pushing Resident 3, causing her to fall and sustain a right hip fracture. The facility's investigation, supported by video evidence and staff interviews, substantiated that abuse occurred, as Resident 3 suffered significant injury as a result of the altercation.