Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when a resident with Lewy Body Dementia, who had a care plan noting potential for behaviors directed at others due to cognitive impairment and decreased impulse control, displayed physical aggression toward another resident. The incident occurred when the resident, while seated in a recliner, noticed another resident approaching and responded by gesturing in a 'shooing' manner, then rising and making physical contact by pushing and grabbing the other resident's arm and wrist, causing a momentary loss of balance. The aggressive resident continued to push the other resident, who eventually sat down nearby. When the second resident attempted to stand again, the first resident made a fist and raised it toward the other's face, though no strike occurred, and then shoved the resident in the stomach with both hands. A nurse observed the altercation and intervened to separate the two residents. Neither resident appeared to recall the event, and no injuries were noted. The care plan for the aggressive resident had identified risks for such behaviors, but the incident still occurred, indicating a failure to ensure residents remained free from abuse as required by facility policy.