Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of behavioral symptoms was physically struck twice on the right arm by another resident, who also had severe cognitive impairment and a documented history of aggression toward others. The incident took place in the memory care unit, where both residents resided. The staff member on duty, an LVN, heard yelling and witnessed the physical contact, after which the residents were separated and assessed for injuries. No injuries, redness, or swelling were noted, and neither resident was able to recall the incident during subsequent interviews. The resident who initiated the physical contact had a documented pattern of aggressive behavior, including multiple prior altercations with other residents. His care plan reflected these behaviors, with interventions such as one-to-one monitoring and behavioral health referrals following previous incidents. Despite these interventions, the resident continued to exhibit aggressive outbursts, and staff were unable to identify consistent triggers for his behavior. The facility had attempted to find alternative placements for this resident due to his ongoing aggression, but these efforts were unsuccessful as other facilities declined to accept him. The facility's abuse prohibition policy states that each resident has the right to be free from abuse, mistreatment, and neglect. However, the repeated incidents of aggression by one resident toward others, culminating in the observed physical abuse, demonstrate a failure to protect residents from abuse as required. The actions and inactions leading to the deficiency include the inability to prevent further aggressive incidents despite known behavioral risks and prior occurrences, as well as the lack of effective interventions to ensure the safety of all residents in the memory care unit.