Resident-to-Resident Physical Abuse Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of unpredictable and sometimes aggressive behavior physically assaulted another resident with significant cognitive impairment. The incident took place in a hallway, where the victim was moving towards the perpetrator. The victim verbally expressed concern, telling the perpetrator not to hit her, but was subsequently punched in the face twice by the other resident. Staff members were present in the area but were not within immediate reach to prevent the altercation. Clinical records and staff interviews revealed that the perpetrator had a documented history of agitation and had previously exhibited aggressive behaviors, including cursing and swinging at staff, though there was no prior documentation of physical aggression towards other residents. The care plan for the perpetrator noted severe cognitive impairment and the need for simple instructions, but did not indicate specific interventions to address the risk of resident-to-resident aggression. The victim sustained a busted lip, bruising, and increased pain, requiring a physician assessment and medication adjustment. Facility documentation and interviews confirmed that the staff responded quickly after the incident, but the initial failure to prevent the altercation resulted in physical harm to the victim. The facility's policy prohibits all forms of abuse, including resident-to-resident abuse, but the measures in place were insufficient to protect the victim from harm in this instance.