Failure to Prevent Resident-to-Resident Abuse in Memory Care Unit
Penalty
Summary
The facility failed to ensure that residents were protected from abuse and neglect, as evidenced by an incident in which one resident slapped another resident in the face. Both residents involved had severe cognitive impairments and resided in the memory care unit. The resident who was slapped had diagnoses including dementia and required assistance with personal care, while the resident who committed the act had dementia, schizophrenia, bipolar disorder, and a cognitive communication deficit. The incident was witnessed indirectly when a staff member heard a slap and another resident pointed out the aggressor. The resident who was slapped touched her face and indicated she was okay, but due to her cognitive status, she did not remember the incident or provide further information during interviews. The resident who committed the act had a documented history of verbal behavioral symptoms and poor impulse control, as reflected in her care plan. Prior to the incident, her care plan included interventions for managing behaviors, but she was not on 1:1 monitoring until after the event. Staff interviews revealed that the resident had previously exhibited verbal aggression but had not been observed physically assaulting others before this incident. The staff member present at the time did not witness the actual slap but responded after being alerted by another resident and by the noise. The facility's policy states that residents have the right to be free from abuse, including abuse by other residents. The incident was reported to the appropriate staff, and documentation confirmed that the event occurred. Both residents were unable to recall the incident during follow-up interviews, likely due to their cognitive impairments. The deficiency centers on the facility's failure to prevent the occurrence of resident-to-resident abuse, despite known behavioral risks and care plans indicating the potential for such behaviors.