Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of dementia was physically abused by another resident who was cognitively intact. The incident took place in the patio area, where the cognitively intact resident pushed the other resident in the face with his forearm, resulting in a bloody nose. The aggressor stated that he acted to block the other resident, who had his pants down and was attempting to have a bowel movement on the patio. Staff interviews and clinical record reviews confirmed the incident and the resulting injury. The facility was aware that the resident with dementia had a pattern of having bowel movements on the patio, but this behavior was not effectively managed or prevented. Staff, including a CNA and the DON, acknowledged knowledge of the ongoing issue. The facility's policy on abuse and neglect defines abuse as the willful infliction of injury with resulting physical harm, which was consistent with the events described. The failure to prevent the altercation led to physical harm to a vulnerable resident.