Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with cognitive and communication deficits, who was incapable of making her own healthcare decisions, was physically abused by another resident with a history of bipolar disorder and aggression. The incident involved the aggressive resident striking the vulnerable resident on the left side of her forehead with a closed fist, resulting in a visible bruise and a hematoma. The assaulted resident exhibited fear and distress, manifested by crying and avoidance behaviors, particularly when the aggressor was present in the room. Prior to the incident, the aggressive resident had documented daily physical behavioral symptoms directed towards others, including verbal and physical aggression. The care plan for this resident noted a history of uncontrolled anger and poor impulse control, with instructions to assess and anticipate needs and to immediately separate parties involved in confrontations. Despite these documented risks and interventions, the aggressive resident was able to physically assault her roommate, indicating a failure to prevent abuse as outlined in the facility's abuse prevention policy. Multiple staff interviews confirmed the aggressive behaviors, including yelling, cursing, and physical threats towards both residents and staff. The assaulted resident was unable to verbally express herself due to her medical condition but demonstrated fear through nonverbal cues and crying. Staff, including the DON, Social Services Director, and an LPN, all acknowledged the abusive behavior and its impact on the assaulted resident, confirming that the facility did not ensure the resident's right to be free from abuse.