Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident, who had severe cognitive impairment and a history of aggressive behaviors, struck the resident on two separate occasions. The resident who committed the acts had diagnoses including psychotic disorder, obsessive compulsive disorder, and dementia, and was known to become agitated, yell, and hit others when frustrated. Despite these known behaviors, the resident was not always supervised, and incidents occurred in the dining hall where the resident hit another resident on the arm. Documentation shows that staff and management were aware of the resident's behavioral tendencies, but the supervision and interventions in place were insufficient to prevent repeated physical contact. The resident who was struck had mild cognitive impairment and required substantial assistance with activities of daily living. On both occasions, the resident reported being hit in the dining room, and staff assessed for injuries, finding none. The incidents were documented in nursing progress notes, and notifications were made to the administrator, guardian, and provider. However, there was no evidence of consistent or effective measures to prevent further occurrences, as the same pattern of behavior recurred, and staff interviews indicated that the aggressive resident was sometimes left unsupervised. Interviews with staff and other residents confirmed that the aggressive resident had a pattern of yelling, hitting, and threatening others, and that staff were aware of the risk but did not always provide adequate supervision. Residents reported feeling the need to avoid the aggressive resident, and staff acknowledged that residents have the right not to be hit by anyone. The facility's failure to provide sufficient supervision and protection allowed repeated physical abuse to occur, violating the policy that each resident should be free from abuse and harm.