Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident, resulting in two separate incidents. In the first incident, a resident with moderate cognitive impairment and a history of Alzheimer's disease, anxiety, and insomnia was observed holding another resident's hands down on their abdomen and squeezing their jaw. This resident had previously exhibited verbally and physically aggressive behaviors, including threatening other residents and staff, and had required frequent redirection and supervision. The victim in this incident had moderate cognitive impairment, a history of stroke, dementia, and hemiplegia, and required substantial assistance with activities of daily living. In the second incident, the same aggressive resident pushed another resident against a wall and was observed being threatening. The victim in this case had severe cognitive impairment, traumatic brain injury, dementia, and arthritis, and also required substantial assistance with daily activities. Both incidents were witnessed by staff, who intervened to separate the residents. Documentation and interviews confirm that the aggressive resident had a pattern of agitation and aggressive outbursts, particularly in response to loud noises or other residents' behaviors, and that staff had to frequently redirect and monitor this individual. Despite the known behavioral risks and the facility's policies to prevent abuse, the aggressive resident was able to physically assault two other residents. The facility's records show that the aggressive resident had a history of escalating behaviors, including threats and physical altercations, prior to the incidents. Staff interviews confirmed that the incidents were recognized as potential abuse and that the residents involved had not previously had issues with one another. The facility's failure to prevent these altercations resulted in a deficiency related to protecting residents from abuse.