Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A resident with severe cognitive impairment and multiple psychiatric diagnoses was involved in an incident where another resident, who also had moderate cognitive impairment and psychiatric conditions, physically assaulted them. The aggressor was found gripping the other resident's arm and making verbal threats to kill, based on delusional beliefs that the roommate had committed murders. Staff intervened by physically separating the residents and removing the aggressor from the room. The assaulted resident sustained mild redness to the arm as a result of the incident. Prior to the incident, there were no indications in the report that the facility had identified or addressed the risk of aggressive behavior from the resident who became physically and verbally abusive. The aggressor exhibited acute changes in mental status, including delusions, agitation, and confrontational behavior, which were observed by staff and documented in progress notes. The incident was witnessed by staff who intervened after hearing raised voices and observing the physical altercation in progress. The facility's policies on resident rights and abuse prevention require protection from physical and psychosocial harm. However, the report documents that the resident's right to be free from physical abuse was not upheld, as the physical assault occurred before staff intervention. The deficiency centers on the facility's failure to prevent the abusive event, resulting in harm to a resident.