Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and multiple medical conditions, including Alzheimer's disease and anxiety disorder, was physically abused by her roommate. The incident took place after an argument between the two residents, during which the roommate, who was severely cognitively impaired and had a documented history of aggressive behaviors, pushed the resident. This resulted in the resident falling to the floor, sustaining a laceration to the back of her head and a fracture to her right elbow, requiring transfer to an acute care hospital for treatment. The roommate involved in the altercation had a care plan in place due to her potential for physical and verbal aggression, including behaviors such as throwing items, yelling, and arguing with other residents. Staff interviews confirmed that the roommate had a pattern of losing her temper and displaying aggressive behaviors toward other residents, both in the room and in common areas. Despite these known risks, the two residents continued to share a room, and staff intervention only occurred after the altercation had already escalated to physical violence. Facility policy required staff to monitor residents for aggressive or inappropriate behaviors and to recognize behaviors that could provoke reactions, such as verbal or physical aggression and invading personal space. In this case, staff responded after hearing the argument and the incident had already resulted in injury. The failure to prevent the altercation and protect the resident from physical abuse constituted a violation of the resident's right to be free from abuse and neglect.