Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with moderately impaired cognition and multiple medical conditions, including dementia, diabetes, depression, anxiety disorder, and Parkinson's disease, was not protected from physical abuse by another resident. The incident took place when another resident, who had severely impaired cognition and a history of neurological and behavioral diagnoses, grabbed the first resident's shirt around the neck, stretching the fabric, and bit her hand. The victim sustained a visible bite mark on the back of her left hand and redness to her chest, resulting in pain, anxiety, and emotional distress. The records indicate that both residents had no prior documented behaviors or care plan interventions addressing aggression or risk of resident-to-resident altercations. The incident was witnessed by staff who responded to a disturbance in the facility's entrance/lobby area. Upon arrival, staff found the victim pressing her hand against her chest and standing a few feet away from the aggressor, who was seated in a wheelchair. Immediate assessments revealed the physical injuries described, and the aggressor was subsequently sent to the hospital for evaluation due to his aggressive behavior and a change in baseline condition. Interviews with staff and the residents confirmed that the two individuals had previously sat together in the dining room and that, following the incident, the victim chose to avoid the aggressor. The facility's policy states that all residents have the right to be free from abuse by anyone, including other residents. However, the lack of prior behavioral interventions or monitoring for either resident contributed to the failure to prevent this episode of physical abuse.