Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse involving a resident-to-resident altercation. One resident with a history of aggressive behaviors related to dementia, agitation, and physical aggression was involved in an incident with another resident who also had cognitive impairment and behavioral issues. The aggressive resident was documented as being agitated, cussing, and swinging at staff, and was noted to have ongoing behavioral disturbances since admission. The care plan identified the resident as being at risk for abuse and aggressive behaviors, but behavior tracking did not document that the resident was removed from areas causing agitation. On the day of the incident, an LPN heard one resident threaten to throw hot chocolate on the other, followed by the actual act of throwing the liquid. In response, the other resident placed both hands in a choking motion and made contact with the resident's neck. Staff immediately separated the residents, and the resident who threw the liquid was moved to another wing. The incident was reported to the physician, power of attorney, ombudsman, and local police, and an investigation was initiated. Observations after the incident noted a bruise on the cheekbone of the resident with aggressive behaviors, but no other visible injuries. Interviews with staff and residents confirmed the altercation and the ongoing behavioral challenges of the residents involved. The facility's documentation showed that interventions were in place for managing behaviors, but there was no evidence that the resident was removed from the area that was causing agitation prior to the incident. Both residents had complex medical and behavioral diagnoses, including dementia, mood disturbances, and physical health issues, which contributed to the risk of altercations.