Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from physical abuse by another resident. According to the facility's initial report and staff interviews, two residents with cognitive and behavioral diagnoses were involved in an altercation at the nurse's station. One resident, who had a history of anxiety, agitation, poor impulse control, and documented behavioral problems, accused the other of stealing a fan and proceeded to strike the other resident on the shoulder with an open hand. Staff present at the time attempted to separate the residents, but the physical contact still occurred. The incident was witnessed by a CNA and corroborated by an LPN, who described the aggressor as having a tendency to become agitated and verbally aggressive. Both residents involved had documented cognitive impairments and behavioral health issues, including dementia, anxiety, and depression. The facility's abuse policy prohibits abuse of any kind and commits to protecting residents from abuse by anyone, including other residents. Despite these policies and the known behavioral risks, the facility did not prevent the physical altercation, resulting in a failure to uphold the resident's right to be free from abuse.