Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident was not protected from abuse by another resident in the facility's dining room. One resident, with a history of dementia, schizoaffective disorder, bipolar disorder, and traumatic brain injury, physically assaulted another resident by punching him in the face. The incident was witnessed by dietary staff, and the aggressor was noted to have been upset because the other resident was looking at him while he ate. There was no verbal exchange prior to the assault, and the two residents were immediately separated by staff. The resident who was assaulted had a history of malnutrition, myocardial infarction, Type 2 diabetes, unspecified dementia, and depression, and was assessed after the incident. He did not exhibit any physical injuries or pain, and subsequent assessments showed no changes to his skin or signs of emotional distress. The facility's investigation included witness statements and post-incident monitoring, but the event itself demonstrated a failure to ensure the right of the resident to be free from abuse. Interviews with facility leadership revealed that staff were aware of the potential for resident-to-resident abuse, particularly among residents with behavioral issues. The facility had policies and care plans in place for managing behaviors, but the incident still occurred. Staff had been trained on abuse and neglect, and interventions such as monitoring and redirection were described, but these measures did not prevent the physical assault in the dining area.