Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. One female resident with moderate cognitive impairment and multiple medical conditions, including Alzheimer's disease and anxiety disorder, reported being punched by a male resident with severe cognitive impairment, behavioral issues, and a history of aggression. The male resident had a behavioral care plan in place due to his potential for physical aggression, poor impulse control, and communication deficits, but there was no documentation of an abuse care plan for the female resident prior to the survey. On the day of the incident, the male resident became agitated and struck the female resident, resulting in redness and swelling on her face. No staff were present in the day room at the time of the incident, and the event was not witnessed. Multiple staff interviews confirmed that the male resident had a pattern of aggressive behavior, particularly toward female residents and staff, and that the female resident remained fearful and anxious after the incident. The absence of staff supervision in the day room contributed to the occurrence of the abuse. Documentation and interviews revealed that the female resident continued to experience fear and anxiety, avoiding therapy and requiring frequent reassurance for her safety. Staff acknowledged the ongoing behavioral challenges of the male resident and the difficulty in managing his aggression, especially given his communication barriers and cognitive limitations. The lack of adequate supervision and failure to prevent resident-to-resident abuse resulted in the female resident feeling unsafe and threatened within the facility.