Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A resident with dementia and severely impaired cognition, who was independently ambulatory, entered the room of another resident with a history of traumatic brain injury and mood disorder, also with severely impaired cognition. The resident whose room was entered had a documented history of becoming verbally upset and agitated when others entered his personal space, with two prior incidents of yelling and cursing at other residents who entered his room. Despite these prior incidents, no new interventions were implemented to prevent further altercations. On the date of the incident, staff overheard yelling and found the first resident on the floor in the second resident's room. While staff assisted the resident off the floor, the resident whose room was entered struck the other in the face, resulting in a bloody nose and facial bruising. The facility's failure to implement interventions after the initial two incidents allowed for a third altercation, which resulted in physical harm to the resident.