Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from abuse when one resident with severe cognitive impairment slapped another resident, also with severe cognitive impairment, across the right side of the face. The incident occurred when one resident was attempting to open a door to the courtyard and the other resident, standing nearby, spontaneously slapped her. This event was witnessed by a CNA, who reported that her back was initially turned and she did not see the events leading up to the slap, but turned around in time to see the physical contact occur. Both residents involved had diagnoses of dementia and were assessed as having severe cognitive impairment according to their MDS records. The facility's policy and procedure on abuse, dated April 2025, states that each resident has the right to be free from abuse, including physical abuse, and that residents must not be subjected to abuse by anyone. Interviews with staff, including a CNA, a licensed nurse, and the DON, confirmed the occurrence of the incident and acknowledged that such behavior constitutes abuse and is not tolerated according to facility policy.