Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with dementia and behavioral disturbances was not protected from physical abuse by another resident with a history of socially inappropriate and disruptive behaviors. The incident took place in a common area, where one resident, aggravated by the other's habit of counting out loud, approached from behind and placed his hands over the other resident's ears, moving the resident's head side to side. This event was witnessed by a CNA, who intervened and separated the residents. No injuries were observed, but the resident who was subjected to the physical contact was unable to defend himself due to cognitive impairment. The resident who initiated the contact had a documented history of behavioral symptoms requiring continuous supervision and interventions such as redirection. Despite these known risks, the resident was able to approach and physically interact with another resident in a manner that constituted abuse. The care plans for both residents acknowledged their cognitive and behavioral challenges, but the measures in place did not prevent the altercation from occurring. Staff interviews confirmed that the incident was reported to supervisory staff and documented in the clinical records. The facility's policy states that residents have the right to be free from abuse, and the administrator acknowledged that the event constituted physical abuse. The report details the sequence of events and the failure to prevent resident-to-resident abuse, as well as the facility's recognition of the incident as a violation of resident rights.