Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents from abuse by other residents. In the first incident, a female resident with severe cognitive impairment and multiple medical conditions, including metabolic encephalopathy and a stage 3 pressure ulcer, was sitting in her geri chair near the nurse's station. A male resident with Alzheimer's disease and vascular dementia, who was dependent on staff for most activities of daily living, approached her in his wheelchair and inserted his hand into her shirt, groping her breast. The incident was witnessed by several staff members who intervened immediately, and the male resident admitted to the inappropriate contact during an interview. The female resident confirmed the incident when interviewed by the social worker. In the second incident, a male resident with moderately impaired cognition and a history of aggressive behaviors was involved in an altercation with another male resident diagnosed with Alzheimer's disease, bipolar disorder, and unspecified psychosis. The resident with Alzheimer's was observed on facility camera footage to have his path blocked by the other resident in a wheelchair. In response, he lifted the wheelchair, causing it to fall backward, and then punched the resident in the nose. The injured resident sustained redness to his nose as a result of the altercation. Both residents had documented histories of behavioral issues and required significant assistance with daily activities. Both incidents were directly observed by staff or captured on facility cameras, and the involved residents had care plans indicating cognitive impairment and behavioral risks. The facility's failure to prevent these resident-to-resident abuse incidents constituted noncompliance with regulations requiring protection from abuse, as evidenced by the physical and sexual abuse that occurred.