Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents' rights to be free from physical abuse, as evidenced by multiple incidents involving four residents. One resident with severe cognitive impairment and diagnoses including Major Depressive Disorder, Anxiety Disorder, Alzheimer's Disease, and Dementia with Psychotic Disturbance, struck another severely cognitively impaired resident with an open hand on the cheek during an altercation in a hallway. Staff observed the incident and intervened, but the altercation resulted in distress for both residents involved. Documentation shows that both residents had significant cognitive impairments, and the incident was reported to the state agency. In another series of incidents, a cognitively intact resident with Parkinson's Disease, Atherosclerosis, Prostate Cancer, and Aphasia pushed and kicked a severely cognitively impaired resident with Dementia, Psychosis, and Depression after being touched by her in the dining room. Multiple residents and staff reported that the cognitively impaired resident frequently touched others, which was unwelcome and led to physical responses from other residents, including being punched and kicked. Staff and residents acknowledged ongoing issues with this behavior, and staff interviews confirmed awareness of the situation, but the touching and resulting altercations continued to occur.