Failure to Protect Residents from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident, resulting in substantiated incidents of abuse. In the first incident, a resident with a history of cognitive impairment and behavioral symptoms, including aggression and confusion, entered another resident's room without permission and physically grabbed her by the hair. This event was witnessed by staff, who intervened immediately. The victim, who also had moderate cognitive impairment and required some assistance with activities of daily living, did not recall the incident in detail and reported no injury, but staff and the facility's investigation confirmed the physical contact occurred. In a separate incident the following day, the same resident with behavioral disturbances approached another resident near the nurses' station and grabbed her arm. This incident was directly observed by a CNA, who intervened to separate the residents. The victim in this case had significant physical and cognitive impairments, including hemiplegia and dependence on staff for most activities of daily living. She reported no pain or fear as a result of the incident and continued her routine without issue. Both incidents were substantiated by the facility's internal investigations, which included staff and resident interviews, record reviews, and direct observations. The reports indicated that the assailant resident had a documented history of behavioral symptoms and was known to respond to external stimuli with physical contact. The facility's policies required immediate response and increased supervision in such cases, but the incidents occurred nonetheless, resulting in physical abuse of two residents.