Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A resident with fully intact cognition and a history of pressure ulcers and heart failure was struck in the face by another resident diagnosed with Alzheimer's disease and severe memory impairment. The incident occurred after the resident with Alzheimer's complained about television noise, prompting the first resident to turn off the TV. When staff left the room, the resident with Alzheimer's returned, grabbed the other resident's arm, and punched him in the left eye area. The injured resident reported pain and blurry vision, and a licensed nurse documented mild redness and swelling to the left eyebrow. Prior to this incident, the resident with Alzheimer's had documented behavioral issues, including hitting, kicking, and scratching others on multiple occasions. The facility's policy defined physical abuse as hitting and required identification and intervention in situations where abuse is more likely to occur. Despite these documented behaviors, the facility failed to prevent the assault, resulting in injury to the resident.