Failure to Prevent Resident-to-Resident Abuse and Verbal Threats
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by multiple incidents involving resident-to-resident altercations and verbal threats. In one case, a resident with hemiplegia, hemiparesis, aphasia, and anxiety, who had mild cognitive impairment, was involved in a physical altercation with a cognitively intact roommate. The altercation escalated from an argument over closet space to physical contact, with one resident grabbing the other's arm and being struck in the face in return. Staff witnessed the incident and intervened, but the altercation had already occurred. Another incident involved a resident with vascular dementia and impaired mobility who was struck in the face by another resident known to wander into other rooms. The cognitively impaired resident could not recall the event, but staff confirmed the altercation occurred after hearing distress and intervening. The wandering resident had a history of entering other residents' rooms, and the incident took place when the resident entered the room and pulled the other resident's hair. A further deficiency was noted when a resident with dementia, Parkinson's disease, and confusion was verbally threatened by a roommate with a history of depression and anxiety. The confused resident was found yelling and attempting to get out of bed, prompting the roommate to threaten to strangle them. Staff separated the residents and monitored the situation, but the verbal abuse had already taken place. In all cases, the facility's failure to prevent these incidents and ensure residents were free from abuse constituted a deficiency.