Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
A resident with severe cognitive impairment and a history of sundowning and physical aggression struck another resident in the face with a walker, resulting in a nasal fracture. The aggressor's care plan identified risks for sundowning, poor impulse control, and previous aggressive behaviors, including prior attempts to hit other residents with a walker. Interventions in the care plan included anticipating needs, environmental modifications, and staff interventions to protect others, but these were not effectively implemented at the time of the incident. On the day of the incident, the aggressive resident and the victim were seated next to each other in the dining room before meal service, with no aides present in the room. Staff interviews revealed that the aggressor had previously exhibited similar behaviors, and staff were aware of the need to separate him from other residents and provide close supervision, especially during periods of agitation. Despite these known risks and care plan interventions, the resident was left unsupervised, allowing the incident to occur. Multiple staff members confirmed that the resident had attempted to hit others in the past and that interventions such as seating him near the nurse's station and providing one-on-one care were supposed to be in place. The victim, who had moderate cognitive impairment and a history of behavioral symptoms, sustained a minimally displaced nasal fracture and expressed ongoing fear and distress following the incident. The facility's abuse prevention policy required staff to provide a safe environment and monitor care to ensure residents are free from abuse or mistreatment. However, the lack of staff presence and failure to follow care plan interventions directly contributed to the resident-to-resident altercation and resulting injury.