Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when one resident deliberately made physical contact with another resident, resulting in a skin injury. On the date of the incident, one resident, who had intact cognition and a history of behavioral symptoms including physical and verbal aggression, approached another resident seated outside a room and began shouting and behaving aggressively. The second resident, who had impaired cognition and lacked decision-making capacity due to dementia and epilepsy, responded verbally, after which the first resident used his right hand to graze the second resident's left cheek. The incident was witnessed by the Director of Staff Development, who was present and attempted to intervene by standing between the two residents with her arms extended. Despite this, the aggressive resident was able to make physical contact with the other resident's face with the intent to cause injury. Documentation and interviews confirmed that the contact was intentional and met the facility's definition of abuse, as it was a purposeful act intended to inflict harm. The facility's policy clearly states that each resident has the right to be free from abuse, and both the Director of Nursing and the Administrator acknowledged that the incident constituted abuse and was not unavoidable. The facility did not follow its own policy and procedure for the prevention of abuse, resulting in a failure to protect the resident from harm while under the facility's care.