Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with a history of violent behavior, dementia with behavioral disturbance, and moderate cognitive impairment physically assaulted another resident in the dining room. The incident began when the first resident, while self-propelling his wheelchair, unintentionally ran into the second resident, who was non-verbal and attempting to move away. In response, the first resident became upset and struck the second resident in the face three times with a closed fist, resulting in bruising and broken glasses. The altercation was witnessed by nursing staff, who intervened to separate the residents. The first resident's care plan had previously identified risks for verbal and physical aggression related to his dementia and behavioral history. Staff interviews revealed that the resident had a pattern of aggressive outbursts, including screaming and combative behavior when angered. Despite these known behaviors, staff present at the time of the incident were not able to prevent the assault, and some staff expressed fear of the resident and a lack of training to manage such behaviors. The incident caused distress among other residents in the dining room, who needed reassurance of their safety. The facility's policy on abuse prevention included provisions for staff training in abuse prevention, identification, and dementia management, as well as protocols for investigating abuse. However, interviews with staff and the Director of Nursing indicated that there was a lack of adequate behavioral health training for staff, and the mental health provider only participated via telehealth, with limited resident engagement. This contributed to the facility's failure to protect residents from abuse as required.