Failure to Prevent Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident. An incident occurred between two roommates, one with diagnoses including metabolic encephalopathy, dementia with agitation, and a history of wandering, and the other with cognitive impairment and behavioral symptoms. The incident was documented in an investigation file, which noted that staff responded immediately to intervene and separate the residents after a physical altercation took place in their shared room. Staff statements indicated that the two residents exchanged words, engaged in hitting and kicking, and that yelling was heard from the room. One resident reported being hit and responding by hitting back. The care plans for both residents documented behavioral concerns, including wandering and behavioral symptoms, but the altercation still occurred, resulting in a failure to ensure the residents' right to be free from physical abuse.