Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by another resident, resulting in an incident where one resident with dementia and a history of aggressive behavior physically grabbed and struck another resident. The incident occurred while residents were waiting in line to go outside to smoke, when the resident with dementia approached from behind and grabbed the other resident's shoulder, causing the latter to yell and express fear. Witnesses confirmed the aggressive behavior, and it was noted that this was not the first time the resident had exhibited such conduct toward others, including attempts to hit and invade personal space of multiple residents. The resident who committed the abuse had a documented history of dementia, behavioral disturbances, and post-traumatic stress disorder, with care plans indicating episodes of physical aggression and resistance to care. Interventions such as increased supervision and 10-minute checks had been implemented previously due to these behaviors. Staff interviews revealed ongoing concerns about the resident's confusion, anger, and tendency to enter other residents' rooms, as well as difficulties in redirecting the resident and managing their impulsivity and poor safety awareness. Despite these known risks and behavioral patterns, the facility did not consistently implement or update all interventions in the care plan, such as the use of a doorway sensor, and staff reported challenges in maintaining adequate supervision. The failure to prevent the incident resulted in a resident experiencing physical abuse and fear, with staff and other residents acknowledging ongoing issues with the aggressive resident's behavior.