Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from physical abuse by another resident. One resident with severe cognitive impairment and a history of rummaging behaviors entered the room of another resident who had dementia, cognitive communication deficits, and a known history of verbal aggression when her personal space was intruded upon. The care plan for the resident with a history of aggression included interventions such as early intervention and redirection when agitation was observed, but there was no prior documentation of physical aggression. On the day of the incident, staff were present in the hallway but did not prevent the altercation. The resident with cognitive impairment entered the shared bathroom area, which was considered personal space by the other resident. Within one to two minutes, staff heard a yell and discovered that the resident with a history of verbal aggression had pushed the other resident to the floor and kicked her, resulting in two skin tears and severe pain. Staff interviews confirmed that monitoring and redirection of residents to prevent entry into others' rooms was an expected responsibility, but this was not effectively carried out at the time of the incident. The incident was witnessed by staff, and immediate assessments revealed injuries to the resident who was pushed and kicked. Both residents were unable to recall the incident due to their cognitive impairments. Prior to this event, the aggressive resident had not exhibited physical aggression, but staff were aware of her verbal aggression and the need to monitor and redirect residents to prevent such altercations. The failure to adequately supervise and intervene led to the occurrence of physical abuse.