Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
A resident with dementia and cognitive impairment, who was non-ambulatory and required staff assistance, sustained multiple facial lacerations, swelling, and bruising after being struck in the face by another resident. The injured resident was unable to explain the cause of the injuries due to cognitive limitations. Clinical documentation and staff interviews confirmed the presence of significant injuries, including lacerations to the eyebrow, nose, and cheek, as well as pain and visible bruising. The incident was reported to the resident's physician, and the resident was sent to the emergency department for evaluation. The resident who committed the abuse had a documented history of dementia, anxiety, depression, and frequent episodes of verbal and physical aggression, particularly toward his roommate. Progress notes and care plans indicated repeated threats, aggressive statements, and attempts at physical aggression toward the injured resident over several weeks. Staff and therapy personnel observed ongoing verbal aggression and threats, and the care plan for the aggressive resident included interventions such as monitoring, redirection, and reporting behaviors to the physician. Despite these interventions, the aggressive resident was able to strike his roommate, resulting in injury. Facility records and staff interviews revealed that the administration was aware of the ongoing verbal aggression and threats but had not observed prior physical violence. The facility's abuse prevention policy emphasized the right of residents to be free from abuse by anyone, including other residents. However, the measures in place were insufficient to prevent the escalation from verbal to physical abuse, resulting in harm to a vulnerable resident. The facility acknowledged responsibility for resident safety and supervision but did not provide evidence that effective interventions were implemented to prevent the incident.