Failure to Protect Residents from Abuse During Resident-to-Resident Altercation
Penalty
Summary
The facility failed to ensure the right to be free from abuse for two residents, resulting in an incident where one resident physically assaulted another. On the date of the incident, a female resident with dementia, anxiety disorder, and impulse disorder, who had a history of wandering and required redirection, entered the room of a male resident with vascular dementia and severe cognitive impairment. The male resident, who had no prior history of physical aggression, was found by a staff member yelling for the other resident to leave his room. The staff member discovered the female resident in the male resident's room, with personal belongings scattered and water spilled on the floor. According to staff and documentation, the male resident hit the female resident in the face and threw items at her, resulting in immediate bruising to her face, knuckles, and shin. The female resident reported being hit, and a head-to-toe assessment confirmed the injuries. The incident was witnessed by a staff member, who intervened and removed the female resident from the room. Both residents were assessed for safety following the event. Prior to this incident, there were no documented altercations or aggressive behaviors between these two residents, and neither had exhibited physical or verbal aggression toward others according to their care plans and assessments. The facility's abuse and neglect policy required protection of residents from abuse by anyone, including other residents, and mandated prompt reporting and investigation of such incidents. However, the failure to prevent the altercation and protect the residents from abuse constituted a deficiency in upholding resident rights and safety.