Failure to Prevent Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by not adequately preventing a resident with a known history of aggressive and intrusive behaviors from harming others. The resident in question, who had diagnoses including Alzheimer's disease, dementia with behavioral disturbances, and anxiety, exhibited frequent physical and verbal aggression, wandering, and rejection of care. Despite these behaviors being documented in the resident's admission assessment, the facility did not implement sufficient measures to prevent repeated altercations with other residents. Multiple incidents occurred over several months in which the resident physically assaulted or intruded upon other residents. These included a witnessed event where the resident punched another resident in the stomach and chest, entering and sleeping in other residents' beds, and an unwitnessed altercation where a resident reported being punched on the arm and face. Staff and other residents confirmed that the resident frequently wandered into others' rooms, became combative when redirected, and had a pattern of aggressive behavior towards both staff and residents. Interviews with CNAs, nurses, and the unit manager revealed that staff were aware of the resident's behaviors and the ongoing risk posed to others. Although some interventions such as redirection and magnetic stop signs were mentioned, the repeated incidents indicate that these measures were not effective in ensuring the safety of other residents. The facility's failure to adequately supervise and manage the resident's behaviors resulted in multiple instances where other residents were not protected from physical abuse.