Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when one resident shoved another in the hallway. Resident 1, who had a diagnosis of paranoid schizophrenia but was cognitively intact and independent in self-care and mobility, reported being shoved by another resident (Resident 2) during a conversation about arcade games. Resident 2, also cognitively intact and independent, admitted to shoving Resident 1 in the chest after becoming upset. Both residents had a documented history of boundary issues and previous play fighting. The incident was reported to staff, and interviews confirmed that the shove was deliberate and caused distress to Resident 1. Facility records, including care plans and interdisciplinary notes, indicated awareness of ongoing boundary issues between the two residents. Staff interviews revealed that the facility's policy defines such physical contact as abuse, regardless of intent to harm. The facility's abuse prohibition policy was reviewed, which states that any willful infliction of injury or physical contact such as hitting or shoving constitutes abuse. The incident was recognized by staff and administration as a violation of this policy, resulting in a deficiency for failing to ensure residents were free from physical abuse.