Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, resulting in one resident pushing another, causing the latter to lose balance and fall to the floor. The incident involved two residents on a locked dementia unit, both of whom were not cognitively intact. The resident who was pushed had a history of dementia with psychotic disturbance and other chronic conditions, and was ambulatory without assistance. The resident who pushed used a wheelchair and had diagnoses including dementia with anxiety and other chronic illnesses. According to staff interviews and documentation, the resident who was pushed had repeatedly entered the personal space of the other resident, requiring redirection on multiple occasions. On the day of the incident, staff observed the ambulatory resident approach the wheelchair-bound resident twice—first in the hallway and then in the day room. After being redirected the first time, the resident again entered the other's personal space, at which point the wheelchair-bound resident pushed, causing a fall. Staff confirmed that the resident who pushed is known to become aggressive when his personal space is invaded, and that the other resident frequently needs redirection for similar behaviors. The incident occurred while the LPN was down the hall, and staff confirmed the sequence of events as described.