Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent and protect residents from resident-to-resident physical and verbal abuse, affecting two residents out of five reviewed. In one incident, a resident with moderate cognitive impairment and diagnoses including parkinsonism and weakness was pushed by another resident after a verbal disagreement in the hallway, resulting in a minor scrape to the elbow. Staff intervened and separated the residents, and the injured resident reported feeling safe afterward. In a separate incident, another resident with intact cognition and a history of chronic heart failure and mobility issues was punched in the eye by the same aggressor after requesting that the television volume be lowered late at night. The aggressor also yelled derogatory language and threatened further violence. Staff, including an LPN and a CNA, responded to the altercation, attempted to redirect the aggressor, and called for additional assistance when the aggressor became physically and verbally aggressive toward both staff and the other resident. The injured resident declined police involvement and reported no lasting distress. The aggressor resident had a history of major depressive disorder, aphasia, and hemiplegia, with documented moderate cognitive impairment. Care plans noted the resident's risk for abuse and socially inappropriate behaviors, including playing loud music and difficulty with interpersonal interactions. Despite these known risks and previous incidents, the facility did not effectively prevent further altercations, resulting in physical and verbal abuse between residents.