Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by multiple incidents involving three residents. One cognitively intact resident reported being kicked in the knee by another resident, who was also observed blocking and cursing at her in the dining room. This incident was corroborated by a dietary aide and the resident's family member, who was notified by the facility. Another resident, who is severely cognitively impaired, sustained a right knee skin tear after being pushed to the ground by the same aggressive resident. This event was witnessed by a CNA and documented in the resident's progress notes, with the injured resident expressing pain during wound care. The aggressive resident, who is also severely cognitively impaired, had a documented history of physical aggression toward both residents and staff, with care plans and progress notes indicating unsuccessful attempts at redirection. On the day of the incidents, this resident was removed from the dining room after exhibiting aggressive behavior and was later sent to the emergency room for evaluation. Staff interviews confirmed ongoing challenges in managing this resident's aggression, and psychiatric notes indicated an increase in such behaviors prior to the incidents.