Failure to Prevent Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical and emotional abuse when another resident physically assaulted him. The incident involved one resident punching another in the face twice and placing him in a choke hold, resulting in a facial contusion and pain that required transfer to an acute care hospital. The assaulted resident, who had a history of anxiety and dementia, reported feeling fearful and unsafe following the event. Observations and interviews confirmed the details of the assault, with staff witnessing the aggressive behavior and providing immediate assessment and care. The resident who committed the assault had a diagnosis of cognitive communication deficit and dementia with psychotic disturbance, but was assessed as having intact cognitive status according to a recent MDS assessment. This resident had a documented history of four prior aggressive incidents toward other residents, as noted in his care plan. On the day of the incident, a CNA assigned as a sitter to the aggressive resident observed a sudden change in behavior from calm to aggressive, leading to the assault. Staff interviews and record reviews indicated that the aggressive resident's behavior could escalate without warning. The facility's policy and procedure on resident rights, which guarantees freedom from abuse and neglect, was not upheld in this instance. The failure to prevent the assault resulted in physical injury and emotional distress for the victimized resident.