Failure to Prevent Resident-to-Resident Physical Abuse in Memory Care Unit
Penalty
Summary
The facility failed to prevent physical abuse between residents in the Memory Care Unit, specifically involving two residents with dementia-related diagnoses. One resident, who had a documented history of verbal and physical aggression, was assisting with cleaning after a meal and attempted to remove another resident's lunch tray. The second resident reached out as the tray was being removed, and the first resident responded by striking the second resident in the eye. Staff interviews and record reviews confirmed that the incident occurred in the dining area, and that the aggressive resident had a care plan in place addressing behavioral issues, including interventions to minimize disruptive behaviors. At the time of the incident, staff were present in the unit, and an LPN reported hearing a loud noise and observing the aftermath, with the victim covering his eyes and stating he was hurt. Both residents were assessed following the altercation, and no physical injuries were noted. The facility's policies affirm residents' rights to be free from abuse, and the event was reported to the state agency as required. However, the incident demonstrates a failure to effectively implement interventions and supervision to prevent resident-to-resident physical abuse.