Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with a history of hemiplegia, diabetes, and major depressive disorder, who was assessed as having intact cognition and at risk for abuse, was subjected to physical abuse by another resident. The incident involved a second resident with severe cognitive impairment, dementia, schizophrenia, and a history of wandering and resistance to care. This resident entered the first resident's room, struck them with a Reacher, scratched their arm causing a Dexcom sensor to be dislodged, and threatened them with scissors. The incident resulted in visible red scratch marks and the removal of the glucose monitoring device. Prior to the incident, the resident who committed the abuse had documented behaviors of wandering and resistance to care, with care plans indicating the need for monitoring while up in their wheelchair. However, there was no evidence that interventions were implemented to address these behaviors or to protect other residents from potential harm. Staff interviews revealed a lack of awareness regarding specific monitoring interventions for the resident after the incident, and care plans were not updated to reflect new risks or necessary precautions. Facility video footage confirmed that the resident continued to wander unsupervised after the incident, including moving through exit doors undetected. Multiple staff members, including nurses and certified nurse aides, reported being unaware of any additional interventions or monitoring put in place following the altercation. The failure to implement and document appropriate interventions to prevent further incidents contributed to the deficiency in protecting residents from abuse.