Failure to Prevent Repeated Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease and dementia, from repeated physical abuse by another resident with a history of aggressive behaviors and severe cognitive impairment. The abused resident, who was independently ambulatory and had no behavioral symptoms, was subjected to three separate incidents of physical assault by the same peer. These incidents included being hit on the back of the head, being struck and subsequently falling to the ground, and being hit in the face, resulting in visible bruising, redness, and swelling. In one instance, the resident required evaluation at a local hospital, and in another, a facial x-ray was ordered due to the injuries sustained. The aggressor resident had a documented history of impulse control disorder, bipolar disorder, and other psychiatric and neurological diagnoses. Despite previous aggressive incidents, including hitting another resident and swinging a chair at staff and equipment, the interventions implemented by the facility, such as 1:1 monitoring and hourly safety checks, were not sufficient to prevent further assaults. The care plans for both residents acknowledged the risk of behavioral disturbances and the need for close observation, but the measures in place did not effectively prevent repeated abuse. Interviews with staff and family confirmed that the abused resident became more withdrawn following the incidents, and there was concern for her safety. The facility's policies required the protection of residents from abuse by anyone, including other residents, and mandated staff training in abuse prevention and management of aggressive behaviors. However, the repeated incidents of resident-to-resident abuse demonstrated a failure to ensure the resident's right to be free from abuse, as required by both facility policy and federal regulations.