Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from resident-to-resident abuse when one cognitively impaired resident with known behavioral issues physically assaulted another cognitively impaired resident. Resident D, who had Alzheimer's disease and was severely cognitively impaired, was documented in a progress note as having been involved in an altercation in which another resident struck her, causing her glasses to break and resulting in bruising to her face and both arms. A weekly skin assessment the following day documented bruising on both antecubital areas of her arms, the left periorbital area, and the left side of her nose, and later observation showed a fading bruise on her left arm. Resident C, also severely cognitively impaired and ambulatory with supervision, had a documented history of physical behaviors toward others and delusional beliefs that the facility was her home and that others needed to leave. Her care plan included an intervention for staff to intervene as necessary to protect the rights and safety of others. On the date of the incident, progress notes indicated Resident C was wandering in the hallway and could not be redirected, and later became aggressive, yelling at and grabbing Resident D and not being easily redirected by staff. Staff interviews described Resident C as a "walking behavior" who had become more aggressive over the prior two and a half months, with recent physical aggression such as randomly hitting other residents or smacking them, while Resident D was described as non-aggressive and not bothersome to others. The facility’s abuse policy stated residents must not be subjected to abuse by anyone, including other residents.
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