Failure to Prevent Resident-to-Resident Physical Abuse in Secured Unit
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from physical abuse by another resident. The incident took place in the secured unit dining area, where one resident with a history of behavioral disturbances and dementia attempted to take food from another resident. When the second resident refused, the first resident struck her in the head. Staff present separated the residents, and the victim was assessed with no injuries noted. Both residents were unable to recall the incident due to cognitive impairment. The resident who committed the abuse had documented behavioral issues, including aggression, wandering, and attempts to take food from others. His care plan noted these behaviors and included interventions such as providing his meal immediately upon seating and redirecting him as needed. However, the care plan did not specifically address the trigger of resistance or argument when he tried to take items from others. Staff interviews confirmed that this resident frequently wandered, attempted to take food from others, and could become aggressive if confronted or not redirected promptly. There was also a prior incident where this resident fell while trying to take food from another resident, resulting in injury to himself. The victim of the abuse was also severely cognitively impaired and required supervision or assistance for most activities of daily living. She did not have a history of behavioral issues and was not involved in previous incidents. Staff and representatives confirmed that she would become upset if others tried to take her belongings but had not previously had altercations with other residents. The facility's failure to anticipate and prevent the interaction between these two residents, despite known behavioral risks, led to the occurrence of physical abuse.