Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, as evidenced by an incident in which one resident with severe cognitive impairment struck another resident multiple times. Both residents had significant cognitive deficits, with one diagnosed with dementia and anxiety disorder, and the other with Alzheimer's disease and chronic kidney disease. The incident occurred in a common area near the nursing station, where a certified nursing assistant observed one resident hitting another on the arms and using profane language. The staff member intervened and separated the residents after witnessing the altercation. Interviews with staff confirmed that the event was observed and reported according to facility protocol, but the incident still occurred despite the facility's zero-tolerance policy for abuse. The facility's policy defines physical abuse as hitting, slapping, pinching, or kicking, and the event was documented in the resident's electronic health record. The deficiency centers on the facility's failure to prevent this episode of resident-to-resident abuse, which was directly observed by staff.