Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with a history of physical aggression and impaired cognition pushed another resident to the floor, resulting in a violation of the right to be free from physical abuse. The aggressive resident had diagnoses including dementia, neurocognitive disorder, and poor impulse control, and was known to become physically aggressive with both staff and other residents. At the time of the incident, the resident was experiencing a urinary tract infection, which staff believed may have contributed to the behavior. The incident took place in a corridor when the aggressive resident, feeling blocked by the other resident, used both hands to shove the individual in the chest, causing a fall. The resident who was pushed had Alzheimer's disease, dementia, and was at risk for falls, with a care plan indicating a need for safety monitoring. This resident did not have a history of aggression towards others. After being pushed, the resident fell backwards and reported minor pain near the thigh and pelvic area but did not recall the details of the incident. Staff present at the time witnessed the event and immediately assessed the resident for injuries. The facility's policy required protections against all forms of abuse, including physical abuse, and outlined the need for assessments and interventions for residents with behavioral risks. Despite these policies and the known behavioral history of the aggressive resident, the incident occurred, resulting in a failure to protect a resident from physical abuse by another resident.