Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from abuse when another resident physically assaulted her. On the date of the incident, a resident with a history of schizoaffective disorder, anxiety, and depression, who was known to have potential for physical aggression, pushed another resident to the ground after becoming angry about the other resident entering her room. The assaulted resident, who had moderate cognitive impairment and multiple medical conditions including diabetes, heart failure, and chronic pain, sustained a skin tear on her left elbow as a result of the fall. The incident was witnessed by staff who responded to a scream and found the injured resident on the floor. Interviews and record reviews revealed that the aggressive resident had a documented care plan addressing her potential for physical aggression, with interventions such as staff intervening before agitation escalates and guiding her away from sources of distress. Despite these interventions, the resident became agitated and physically pushed the other resident, resulting in injury. The injured resident reported the assault to staff and requested that the police be called. Staff and other residents described the aggressive resident as a loner who could become impulsive and aggressive when triggered, while the injured resident was described as calm and helpful. The facility's failure to prevent the assault and injury constituted noncompliance with regulations requiring residents to be free from abuse, neglect, and mistreatment. The incident was reported to the appropriate authorities, and the facility's own investigation confirmed that the aggressive resident had pushed the other resident, causing her to fall and sustain an injury. The deficiency was identified as past noncompliance, with the noncompliance period beginning on the date of the incident and ending a few days later.