Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of agitation and aggression was not adequately protected from engaging in abusive behavior toward another resident. The resident, who had diagnoses including Alzheimer's disease, epilepsy, and depression, was known to display aggressive behaviors and had a care plan in place to address these issues. Despite interventions intended to minimize disruptive behavior, the resident was involved in an incident where he physically assaulted another resident, who also had severe cognitive impairment and multiple medical conditions. On the evening of the incident, the aggressive resident was observed pushing another resident against a door and allegedly punching him in the ribs. Documentation indicated that an x-ray was ordered to rule out injuries, and monitoring for bruising was initiated, but there were no findings of injury in the clinical record, and no x-ray results were documented. Staff interviews confirmed awareness of the resident's behavioral issues and the altercation, with staff describing the behavior as abusive and noting that the resident had previously exhibited aggression, including an incident involving a butter knife, though details of that event were not documented elsewhere. Facility policy required protection of residents from all forms of abuse, including physical abuse by other residents. However, the facility failed to prevent the altercation, and documentation and follow-up regarding the incident were incomplete. The aggressive resident was subsequently sent to the hospital for placement, but the deficiency centers on the failure to protect residents from abuse and to ensure thorough documentation and assessment following the incident.