Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect multiple residents from physical abuse by other residents, as evidenced by several documented incidents. One resident with Huntington's disease and severe cognitive impairment was slapped on the neck and had her hair pulled by another resident with alcohol-induced dementia and psychosis. This incident was witnessed by an LVN, who observed the aggressor hitting the resident in the face and pulling her hair while both were in wheelchairs in the hallway. The same resident was later punched in the arm by the same aggressor during another incident, which was also witnessed by staff. In both cases, the residents were separated, and the aggressor was returned to his room, but the incidents still occurred despite staff awareness of a history of resident-to-resident incidents between these individuals. Another incident involved a resident with vascular dementia pushing a resident with Alzheimer's disease and PTSD, causing the latter to fall in the dining room. This event was witnessed by a contracted lab technician, who saw the push and subsequent fall. The resident who fell was upset but not injured, and both residents were separated following the incident. The aggressor was placed on 1:1 monitoring, but the altercation had already taken place, indicating a failure to prevent physical abuse between residents. The residents involved in these incidents had significant cognitive and behavioral health diagnoses, including Huntington's disease, bipolar disorder, schizoaffective disorder, alcohol-induced dementia, psychosis, vascular dementia, Alzheimer's disease, and PTSD. Care plans for these residents included interventions such as monitoring for behaviors, redirection, and 1:1 interaction as needed. Despite these interventions being documented, the facility did not prevent the physical altercations, and staff were aware of the potential for such incidents due to the residents' histories and diagnoses.