Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents' rights to be free from physical abuse by other residents, as evidenced by multiple incidents involving residents with cognitive impairments. In one incident, a resident with Alzheimer's Disease and a history of combative behavior struck another cognitively intact resident in the dining room. The altercation was witnessed by a CNA, who attempted to intervene but was unable to prevent the physical contact. The aggressor resident was also noted to have been involved in prior altercations with both staff and other residents, and their care plan included interventions to monitor their whereabouts and behaviors. Another incident involved two residents, both with dementia or Alzheimer's Disease, where one resident struck another in the arm after a verbal exchange. This event was witnessed by a CNA and a family member, and the aggressor resident was documented as having severe cognitive impairment and exhibiting verbal and physical behaviors towards others. The care plan for this resident included recognition of their behavioral risks, but the physical altercation still occurred. A third incident involved two residents with Alzheimer's/Dementia, where one resident, known to have aggressive behavior and at risk for abuse/neglect, struck another resident on the thigh after a verbal confrontation. This resulted in a small red mark. Staff were aware of the ongoing verbal conflicts between these two residents and had interventions in place to redirect and separate them, but the physical abuse still occurred. In all cases, the facility's policies affirming residents' rights to be free from abuse were not effectively implemented, leading to physical altercations among residents.