Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent physical abuse between residents for two individuals with cognitive impairments. In one incident, a resident with cerebral palsy and moderate cognitive impairment alleged that her roommate, who was severely cognitively impaired, hit her in the face. This was corroborated by a certified nurse aide who witnessed the event. Documentation shows that the resident was able to recall the incident and requested a new roommate, while the alleged aggressor was noted to have a history of hitting. Both residents were assessed, and no signs of psychosocial or mental anguish were documented at the time. In a separate incident, another resident with severe cognitive impairment was reported to have been struck on the head by a fellow resident, also with severe cognitive impairment, in a hallway. The alleged aggressor denied hitting but admitted to possibly bumping wheelchairs. Staff documentation indicated that the aggressor also attempted to hit a nurse and used inappropriate language after being confronted. Care plans and health status notes confirm the altercation and the cognitive status of those involved. The facility's abuse policy requires protection from abuse, but these incidents demonstrate a failure to prevent resident-to-resident physical abuse.