Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
A deficiency occurred when a severely cognitively impaired male resident with Alzheimer's dementia and behavioral disturbances physically grabbed the arm of a cognitively intact male resident as the latter was exiting the bathroom. The incident took place when the impaired resident, using a wheelchair, attempted to enter the bathroom and ran into the other resident, subsequently grabbing his arm. The cognitively intact resident responded by hitting the impaired resident's hands in an attempt to free himself. Staff members, including a nurse aide and a nurse, witnessed the event and intervened to separate the residents. The resident who initiated the physical contact had a history of dementia-related behavioral symptoms and was under a care plan that included interventions for managing such behaviors, including medication management and environmental modifications. At the time of the incident, the resident's antipsychotic medication had recently been reduced due to drowsiness, and he was also being evaluated for a urinary tract infection, which can contribute to confusion and behavioral changes. The resident did not recall the incident afterward, consistent with his cognitive impairment. The incident was witnessed by staff, and both residents were assessed for injuries, with one resident showing some redness on his shoulder. Law enforcement was notified, and both residents were interviewed, but neither wished to press charges. The event was substantiated as resident-to-resident abuse based on witness statements and the facility's investigation. The deficiency was identified as a failure to protect a resident's right to be free from abuse by another resident.