Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment from physical abuse by another resident. The incident occurred in a hallway, where a resident with quadriplegia and multiple comorbidities, including dementia and severe cognitive impairment, was sitting in a wheelchair. Another resident, while ambulating with therapy staff, accused the first resident of attempting to trip him and responded by pushing the resident in the shoulder. Staff immediately separated the residents, and an assessment found no injury. Notifications were made to the family, provider, and ombudsman. Clinical record reviews, interviews, and facility documentation confirmed that the resident was vulnerable due to impaired cognition and was at risk for abuse. Staff interviews indicated an understanding of abuse protocols, including immediate intervention and reporting. However, the event demonstrated a failure to prevent resident-to-resident physical abuse, as required by facility policy and federal regulations. The deficiency was identified through review of the incident, resident and staff interviews, and policy review.