Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when one resident intentionally ran over another resident's foot with a wheelchair on two separate occasions during the same incident. The first resident, who was cognitively intact according to a recent BIMS assessment, was observed by staff and other residents to be yelling and screaming at staff before backing his wheelchair over the second resident's foot. When notified by staff that he had run over the other resident's foot, the first resident responded, "I don't care," and proceeded to run over the foot again. Multiple staff members, including a CNA and a Licensed Nurse Supervisor, witnessed the incident and confirmed the sequence of events. The second resident, who had moderate cognitive impairment and a history of anxiety disorder, expressed fear and distress following the incident and stated he did not want to be hit again. The incident was documented in progress notes and corroborated by interviews with both residents, staff witnesses, and the Social Services Director. The facility's policy defines abuse as the willful infliction of injury, and the actions of the first resident were described as deliberate. The second resident reported the incident to staff and indicated a desire to press charges. The administrator acknowledged that abuse is not tolerated at the facility.