Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with a history of aggressive behavior physically abused another resident. The aggressive resident, who had diagnoses including dementia with agitation and behavioral disturbance, was known by staff to exhibit combative and threatening behaviors, including striking out at staff and other residents. On the day of the incident, the aggressive resident approached another resident in a hallway, struck her on the hand, and attempted to kick her. The assaulted resident, who had normal cognitive function and required assistance with personal care and mobility, sustained a bruised right hand and reported feeling upset, uncomfortable, and unsafe following the incident. Staff interviews and record reviews revealed that the aggressive resident was supposed to be monitored hourly due to his known behaviors and tendency to wander. However, documentation showed that hourly monitoring was not consistently performed or recorded as expected. At the time of the incident, there were fewer staff available due to lunchtime coverage, and no staff were present in the hallway where the abuse occurred. The area where the incident took place was not visible from the nurses' station, further reducing the likelihood of timely staff intervention. Multiple staff members, including nurses and CNAs, confirmed that the aggressive resident required close supervision when out of his room to prevent harm to others. Despite this, the lack of adequate monitoring allowed the resident to approach and harm another resident without immediate staff intervention. The facility's own policy required protection of residents from abuse by anyone, including other residents, but this was not effectively implemented in this case.