Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with severe cognitive impairment and diagnoses including dementia and diabetes was physically abused by another resident, who also had severe cognitive impairment and a history of physical aggression. The incident occurred when the aggressive resident approached the first resident in the hallway, began a verbal argument, and then slapped her on the right cheek. There was also an attempt to choke the resident, resulting in redness to her right cheek and neck. The event was witnessed by a CNA, who heard the slap and observed the altercation before staff intervened to separate the residents. Prior to this incident, the aggressive resident had a documented history of behavioral issues, including throwing water on another resident and being difficult to redirect. Her care plan identified risks for physical aggression and outlined interventions such as removing others from the area and maintaining a safe distance. Despite these interventions, the resident was able to approach and physically harm another resident, indicating a failure to protect residents from abuse as required by facility policy.