Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when one resident struck another with a wooden and metal reacher during an altercation. One resident, who had severe memory impairment and multiple diagnoses including dementia, was involved in an incident with her roommate, who was alert and oriented. According to nurse's notes and staff interviews, the altercation began when the resident with dementia lost her balance and fell across her roommate's bed, prompting the roommate to hit her in the face with a stick. The roommate admitted to striking her with the reacher, and both residents sustained minor injuries during the incident. Observations and interviews confirmed that the reacher was accessible to the resident who used it as a weapon, and both residents recalled aspects of the altercation, with one stating that similar incidents had occurred before but were not reported. Staff responded to the commotion and witnessed the physical altercation, noting that both residents were upset. The facility's abuse prevention policy states that residents have the right to be free from abuse, including abuse by other residents, but this policy was not effectively implemented in this case.