Failure to Protect Resident From Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when one resident struck another on the head with an open hand. The abused resident, identified as having dementia, depression, and severely impaired cognition per a recent MDS, was otherwise able to make himself understood, understood others, and had no behaviors noted during the assessment period. His care plan addressed impaired cognitive function with goals for maintaining orientation. A follow-up progress note documented that he had a resident-to-resident encounter over a weekend and that, although he reported not being bothered, staff observed he appeared anxious afterward. In an interview, he stated that another resident had been mean to him, was “messing with him,” had hit him, and sat behind him in the dining room, leading him to try to stay away from that resident. The facility’s investigation file documented an incident report stating that one resident made contact with the other resident’s head using an open hand, with no injuries noted. An LPN reported she separated the two residents after being informed of the incident by another resident witness, and that the alleged aggressor did not deny hitting the other resident, stating the other resident would not be quiet. Observation of the dining room showed the alleged aggressor sitting at a table behind the abused resident. The facility’s Abuse Prevention Program policy defined abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and specifically included hitting and slapping as physical abuse. Despite this policy, the resident experienced physical contact to the head from another resident.
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