Failure to Prevent Resident-to-Resident Physical Abuse Due to Lack of Supervision
Penalty
Summary
The facility failed to protect a resident from physical abuse when one resident with a known history of physical aggression struck another resident multiple times in the face while in the dining room. At the time of the incident, both residents, who had severe cognitive impairment and dementia, were seated at opposite ends of a table. The aggressor resident became physically violent without provocation, and staff were not present in the dining room when the incident began, as one had just left to assist with care elsewhere. The incident was witnessed by a hospice RN who intervened and called for additional staff. Following the altercation, the victim was assessed and initially showed no visible injuries. However, a subsequent skin assessment revealed multiple bruises and scratches on the victim's hands and forearms, consistent with defensive wounds. The victim, who was unable to recall the incident due to cognitive impairment, was otherwise calm and in good spirits during later observations. The aggressor was sent for a psychiatric evaluation after the event. The facility's abuse prohibition policy requires that all residents be free from abuse, including physical harm. Despite the known behavioral history of the aggressor and interventions in place, the lack of staff supervision in the dining room at the time of the incident allowed the abuse to occur. The facility was unable to provide evidence that the victim was kept free from abuse, as required by policy.