Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and a history of negative physical behaviors, including hitting, kicking, and pushing, was not protected from physical abuse by another resident. The resident's care plan identified issues with being protective of personal space and exhibiting negative behaviors toward others. On the day of the incident, the resident entered a common area and became involved in a physical altercation with another resident who also had a history of negative physical behaviors and severe cognitive impairment. The second resident, who was known to be territorial and required supervision and redirection due to wandering and pacing, engaged in a dispute over a bedside table with the first resident. During the altercation, the second resident balled up his fist and struck the first resident on the cheek, resulting in a visible red mark. Staff intervened to separate the residents and prevent further escalation, but the initial physical contact had already occurred. Staff interviews confirmed that both residents had documented behavioral issues and that the altercation was witnessed by a CNA, who reported the incident according to facility protocol. The facility's policy states a commitment to protecting residents from abuse by anyone, including other residents. Despite this, the incident demonstrated a failure to prevent physical abuse between residents with known behavioral risks.