Failure to Prevent Resident-to-Resident Altercation Involving Cognitively Impaired Resident
Penalty
Summary
The facility failed to prevent a resident-to-resident altercation involving two residents, one of whom had severe cognitive impairment and a history of physical behavioral symptoms such as hitting, kicking, and pushing. The resident with cognitive impairment had diagnoses including non-Alzheimer's dementia, anxiety, and post-traumatic stress disorder, and was noted to be confused, agitated, and prone to entering other residents' rooms. Despite these known behaviors, the resident was not provided with one-on-one supervision and staff primarily relied on redirection and periodic checks. Multiple incidents were documented in which the cognitively impaired resident physically interacted with others, including elbowing, shoving, and ultimately slapping another resident. The most recent incident involved the resident entering another resident's room, becoming agitated, and slapping the other resident, who then retaliated. Staff responded by separating the residents, but no injuries were observed. Interviews with staff indicated that the resident required frequent redirection and was difficult to monitor continuously, as she would not remain in one place and did not participate in activities. The care plan for the resident with behavioral symptoms included interventions such as 15-minute checks and keeping distance between her and others when she became physically abusive. However, these interventions were not consistently maintained, and the resident was not provided with enhanced supervision despite a pattern of escalating behaviors. The facility's abuse prevention policy required identification and intervention for high-risk situations, but the measures in place were insufficient to prevent the altercation.