Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. An altercation occurred when a resident with Alzheimer's disease, cognitive impairment, and a language barrier entered another resident's room and did not leave when asked. The second resident, who also has dementia, responded by physically assaulting the first resident, resulting in a 1 cm laceration near the left eye, facial bruising, and a hospital visit for evaluation. Multiple staff members responded to the incident after hearing yelling and found the residents engaged in a physical struggle, with staff and maintenance intervening to separate them. Documentation and interviews confirmed that the assaulted resident frequently wandered into other residents' rooms due to confusion and required redirection, a risk noted in his care plan. Despite the known risk factors, including wandering behaviors and cognitive impairment, the facility did not prevent the resident from entering other rooms or ensure adequate supervision to avoid such altercations. Staff and other residents reported that the resident often entered rooms uninvited, and the incident escalated when he did not leave after being told to do so. The facility's abuse prevention policy requires the prevention of abuse and the establishment of a secure environment, but in this case, the measures in place were insufficient to prevent resident-to-resident physical abuse.