Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents with severe cognitive impairment from physical abuse, resulting in a resident-to-resident altercation. One resident, diagnosed with Alzheimer's disease, dementia with agitation, and other mental health conditions, had a documented history of behavioral issues, including inappropriate verbal and physical conduct toward staff and other residents. The other resident, also with dementia and behavioral challenges, had a care plan addressing her tendencies to hit, kick, and yell at others, as well as a history of altercations and aggressive behavior toward both staff and residents. On the day of the incident, both residents were in the dining area when a verbal exchange occurred. The second resident became agitated when the first resident did not respond to her greeting, leading her to physically strike him on the back. The first resident then reacted by punching her in the chest. Staff present in the area intervened to separate the residents, assessed both for injuries, and found none. Multiple staff interviews confirmed the sequence of events, with one nurse directly observing the physical altercation and describing the aggression involved. The facility's own investigation and staff interviews revealed that both residents had known behavioral triggers and histories of aggression, yet the measures in place were insufficient to prevent the altercation. The facility's policy states that residents have the right to be free from abuse, including physical abuse by anyone. Despite this, the incident occurred in a common area under staff supervision, indicating a failure to adequately protect the residents from physical harm as required by policy.