Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with dementia and right-sided hemiplegia was not protected from physical abuse by another resident with a history of behavioral disturbances, including agitation and aggression. The incident took place in a common area, where the first resident told the second resident to "shut up" after the latter was loudly talking to himself. In response, the second resident stood up and pushed the first resident, causing her to fall and sustain a left wrist fracture. Multiple staff members witnessed or heard the altercation, confirming the sequence of events. The resident who committed the abuse had a documented history of behavioral issues, including yelling at the television and other residents, and had previously exhibited escalating agitation and threatening behavior. His care plans included interventions for managing agitation and physical behaviors, but did not specify actions for guiding other residents away from him when he became agitated or physically aggressive. Staff interviews indicated that the resident was known to be triggered by being told to "shut up," and that staff had previously redirected him or advised other residents not to use such language toward him. Despite the known behavioral risks and triggers associated with the second resident, the facility failed to implement sufficient measures to prevent the altercation. The care plan lacked specific interventions to protect other residents from potential physical aggression, and staff did not intervene before the incident occurred. As a result, the first resident was not safeguarded from abuse and suffered a significant injury.