Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from resident-to-resident physical abuse, as evidenced by an incident involving two residents with cognitive impairments. One resident, diagnosed with unspecified dementia and a BIMS score indicating moderate impairment, had a documented history of behavioral issues, including physical altercations with a roommate. The other resident, with vascular dementia and unable to complete a BIMS interview, was noted to have impaired cognitive function and difficulty expressing needs. Both residents were sharing a room at the time of the incident. On the date of the incident, a CNA discovered the two residents entangled on the floor during routine checks, with one resident sustaining skin tears on both hands and the other presenting with a swollen nose. Interviews with staff revealed that the resident with a history of behavioral issues had previously expressed dissatisfaction with his roommate, citing rummaging through personal belongings and a desire for a different room. Staff also noted that the resident often felt threatened and was territorial, while the other resident was generally not known for aggressive behavior but could become frustrated due to communication difficulties. The care plans for both residents included interventions for their respective cognitive and behavioral challenges, such as monitoring for agitation and arranging compatible roommate placements. However, despite these interventions, the facility did not prevent the altercation, and the residents' ongoing conflicts and behavioral cues were not adequately addressed to ensure their safety and prevent abuse.