Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with dementia, COPD, and hypertension, who was cognitively intact according to a recent assessment, reported being physically abused by another resident with severe cognitive impairment and a history of behavioral issues. The incident involved the alleged perpetrator entering the victim's room, hitting her, and causing visible bruising to her arm and face. Documentation and staff interviews confirmed that the victim reported the abuse to staff, and a skin assessment revealed multiple bruises consistent with her account. The alleged perpetrator had a documented history of wandering, impulsive behavior, and physical aggression, as noted in his behavioral treatment plan. The facility's records show that the two residents had been sharing the same unit for an extended period, and the care plans for both included interventions for supervision and maintaining a safe environment. Despite these interventions, the resident with a history of behavioral symptoms was able to enter the other resident's room and allegedly commit physical abuse. Staff interviews indicated that the incident was reported after the fact, and the victim had to leave her room to alert staff. The facility's investigation included interviews, notification of authorities, and review of video footage, although the footage was no longer available at the time of the investigation. The deficiency was further substantiated by the facility's own policies, which require prompt reporting and thorough investigation of abuse allegations. Staff acknowledged the importance of immediate reporting and recognized the incident as abuse. However, the events leading up to the incident, including the lack of effective supervision and the ability of the perpetrator to access the victim's room, directly contributed to the failure to protect the resident from abuse as required by federal and state regulations.