Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect residents from resident-to-resident abuse, as evidenced by an incident involving two residents with cognitive and behavioral challenges. One resident, who had severe cognitive impairment and a history of wandering and aggressive behaviors, entered another resident's room through a shared bathroom. The second resident, who had intact cognition but was known to be verbally aggressive and did not want others entering their room, responded by physically assaulting the wandering resident, resulting in an abrasion and swelling to the upper lip. Documentation showed that the care plan for the wandering resident included interventions such as staff observation during rounds, monitoring for mood changes, and keeping the resident away from peers whenever possible. Nursing instructions also noted the resident's behaviors of wandering, aggression, and resistance to care. Despite these interventions, the resident was able to access another resident's room unsupervised, leading to the altercation. Staff reported performing hourly rounding and monitoring, and both residents were known to require redirection and close observation due to their behaviors. Interviews with staff confirmed that the wandering resident was last seen in their own room shortly before the incident and that staff typically redirected them when observed wandering. The resident who committed the assault had previously expressed a desire for privacy and resistance to others entering their room. The incident occurred when staff were not present to intervene, and the facility's investigation concluded that there was no credible evidence of neglect, abuse, or mistreatment, despite the physical injury sustained.