Failure to Prevent Resident-to-Resident Physical Abuse Due to Lack of Supervision
Penalty
Summary
The facility failed to provide a safe and protective environment free from physical abuse for one of three sampled residents when a resident with a history of aggressive behavior and dementia physically assaulted another resident in the dining room. The resident who was assaulted had a diagnosis of major depression and intact memory, while the aggressor had moderately impaired cognition and a documented history of physical altercations, poor impulse control, and anger. The care plan for the aggressive resident specified the need for staff supervision in the dining room, but this supervision was not provided at the time of the incident. Multiple staff interviews confirmed that the aggressive resident had been involved in previous altercations and required frequent supervision, which was not consistently implemented. The incident occurred when the assaulted resident attempted to move a chair to sit with a friend, prompting the aggressive resident to hit her in the arm and back of the head. The assaulted resident reported feeling scared and stated this was not the first time she had been attacked by the same individual. Observations and interviews with staff and other residents confirmed ongoing aggressive behavior by the resident with dementia, and that the lack of supervision allowed for repeated incidents of physical abuse. The facility's policy states that residents have the right to be free from all forms of abuse, but this was not upheld in this case.