Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. One resident, who is cognitively intact and dependent on staff for transfers, reported being struck on the back of the neck by another resident with severe cognitive impairment and a documented history of aggressive behaviors. The incident occurred in the main dining room and was witnessed by a CNA, who confirmed that the aggressor became upset when unable to pass and then hit the other resident. The victim experienced neck pain for several days and expressed ongoing fear and emotional distress related to the incident, including crying and avoidance of the aggressor. Multiple staff interviews corroborated the incident and the ongoing impact on the victim, who now becomes visibly upset and refuses to participate in activities when the aggressor is present. The aggressor has a documented pattern of physical and verbal outbursts, including aggression toward others on multiple days, and has previously hit staff. The facility's abuse prevention policy states that residents have the right to be free from abuse, including the willful infliction of injury resulting in physical harm, pain, or mental anguish. Despite this, the facility did not prevent the incident or adequately protect the resident from further psychosocial harm.