Failure to Prevent Resident-to-Resident Abuse Resulting in Serious Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was free from abuse, resulting in a serious incident involving two residents on the memory care unit. One resident, who had a documented history of behavioral symptoms including physical aggression, moderate cognitive impairment, and multiple triggers such as loud noises and perceived threats to personal space, was not under one-on-one supervision at the time of the incident. Despite care plans identifying the resident's risk for aggression and outlining interventions such as monitoring for signs of agitation and providing a quiet environment, the resident was able to approach another resident and physically assault him without immediate intervention from staff. The assaulted resident, who also had moderate cognitive impairment and no history of behavioral symptoms, was punched in the face, causing him to fall against a wall and then to the ground. This resulted in a facial laceration and a fractured hip, requiring hospitalization and surgical admission. Staff present at the time were engaged in routine activities such as passing breakfast trays and administering medication, and although they were aware of the aggressor's behavioral risks, the supervision provided was not sufficient to prevent the incident. Multiple staff interviews confirmed that while staff were generally attentive to the resident's behaviors, there was no dedicated one-on-one monitoring in place at the time of the assault. The facility's failure to implement adequate supervision and preventive interventions for a resident with known aggressive behaviors directly led to the physical abuse and injury of another resident. The incident was witnessed by staff, and immediate actions were taken to separate the residents and provide first aid, but the lack of proactive measures to prevent such an occurrence constituted noncompliance with regulations requiring protection from abuse. The event was identified as past noncompliance and resulted in Immediate Jeopardy due to the risk of harm and severe injury to residents.