Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to ensure that a resident was protected from abuse when another resident physically assaulted her in a third resident's room. The assaulted resident had severe cognitive impairment, as indicated by a BIMS score of 03, and multiple diagnoses including non-traumatic brain dysfunction, non-Alzheimer's dementia, anxiety disorder, and depression. On the day of the incident, she was found with multiple bruises and lacerations on her arms, hands, legs, and head, as documented in skin assessments and progress notes. She was unable to recall the incident due to her cognitive status. The resident who committed the assault had a history of behavioral issues, including physical aggression toward staff, wandering into other residents' rooms, and taking belongings. Progress notes and staff interviews documented several prior incidents where this resident was combative, hit or bit staff, and exposed himself in public areas. Despite these behaviors, he was not consistently monitored in a way that prevented him from accessing and harming other residents. On the day of the incident, staff found him in another resident's room holding a wheelchair footrest in the air, with the assaulted resident present and injured. Staff interviews and witness statements confirmed that the aggressive resident had a pattern of escalating behaviors and that staff had to frequently redirect him. The incident was discovered when a CNA noticed an unusual situation and intervened, finding the injured resident and the aggressor together. The facility's documentation and staff accounts indicate that the aggressive resident's behaviors were known and ongoing, but interventions in place were insufficient to prevent the assault, resulting in physical harm to another resident.