Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. On the date of the incident, a maintenance assistant witnessed one resident lightly hitting another on the cheek after an exchange involving incomprehensible speech and agitation. The maintenance assistant intervened by separating the residents and notifying nursing staff. No injuries were observed on the resident who was struck, and there was no notable change in her baseline mood or cognition following the event. Prior to the incident, both residents involved had documented histories of cognitive impairment and behavioral issues. The resident who initiated the physical contact had diagnoses including Alzheimer's disease, dementia, and agitation, and was known to become irritated when others entered her personal space or when exposed to noise. She also had a history of pain and agitation related to ingrown toenails, which was not addressed prior to the incident due to her inability to consistently verbalize discomfort. The other resident had severe dementia with mood disturbance, exhibited wandering and intrusive behaviors, and was known to disrupt other residents' privacy or activities. Staff interviews revealed that both residents were known to have interactions that could lead to agitation, with one being intrusive and the other sensitive to personal space. Staff attempted to monitor and redirect both residents but did not provide extra supervision or specific interventions to prevent such altercations. At the time of the incident, staff were not present to witness the event, and there was a lack of clear documentation or awareness of the residents' whereabouts immediately prior to the altercation. The care plans for both residents did not fully address the specific triggers or risks associated with their behaviors, contributing to the failure to prevent the abusive incident.