Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in two separate incidents of resident-to-resident physical altercations. In the first incident, a resident with vascular dementia, psychotic and mood disturbances, and anxiety, who was noted to have behavioral symptoms and a history of being short-tempered, struck another resident in the face after a minor collision between their wheelchairs. The resident who was struck had diagnoses including anxiety and metabolic encephalopathy, which can cause confusion and memory loss. The altercation occurred after the aggressor yelled at the other resident to move away and then made physical contact when the request was not met quickly enough. In the second incident, a resident with a history of violent behavior and a care plan noting prior physical altercations slapped another resident on the upper arm while both were seated at a dining table. The resident who was slapped had severe cognitive impairment due to dementia and anxiety. The incident was witnessed by a dietary aide, and the aggressor was identified as having intact cognition. Both incidents demonstrate a failure to prevent resident-to-resident abuse, as required by facility policy.