Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from abuse by another resident. One resident with moderate cognitive impairment and multiple diagnoses, including Alzheimer's disease and dementia, ate another resident's cookie during lunch. The second resident, who had severe cognitive impairment and a history of neurocognitive disorder with Lewy bodies, Parkinson's disease, and traumatic brain injury, responded by swinging at and hitting the first resident on the left ear. Staff intervened to separate the residents, and no physical injuries or pain were reported by the resident who was struck. Staff interviews confirmed that the incident involved both verbal and physical abuse, as the aggressor yelled, swore, and made unwanted physical contact. Facility policy defines abuse as the willful infliction of injury resulting in physical harm, pain, or mental anguish, and states that residents have the right to be free from abuse by anyone, including other residents. The incident was observed by staff, and the facility's policies regarding abuse prevention and resident rights were reviewed as part of the investigation.