Failure to Protect Resident from Abuse by Aggressive Resident
Penalty
Summary
The facility failed to protect a resident from abuse by another resident with a history of aggressive behaviors. Resident R1, who had diagnoses including dementia and moderately impaired cognition, was identified in the care plan as requiring behavior monitoring due to frustration and aggression. Despite interventions such as diversional conversation and redirection, Resident R1 was involved in multiple incidents of physical aggression. On one occasion, Resident R1 entered another resident's room, refused to leave, and physically struck the resident and a staff member who attempted to intervene. On a separate occasion, Resident R1 was observed holding Resident R3 by the arm and striking her in the back with a closed fist while in the dining room. Staff intervened and separated the residents, and no injury was observed on Resident R3. Resident R3, who also had dementia with severely impaired cognition, was the victim in these incidents. The facility's policy required protection of residents from abuse by anyone, including other residents, and emphasized monitoring and intervention for those with behavioral issues. Documentation and staff interviews confirmed that the facility did not ensure Resident R3 was free from abuse by Resident R1, as required by policy and regulation. The Director of Nursing acknowledged the failure to protect the resident from abuse.