Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from resident-to-resident abuse, as evidenced by an incident involving two residents. One resident, who was cognitively intact and had a history of irritability and anger, became upset when another resident, who was severely cognitively impaired and known to wander, began rearranging items on a table during a group activity. The cognitively intact resident verbally expressed frustration and then physically struck the other resident on the buttocks before staff could intervene. Staff interviews confirmed that the incident occurred during a prayer meeting service, with the cognitively impaired resident not responding to questions about the event and the other resident denying any problems. The facility's policy states that all residents have the right to be free from abuse by anyone, including other residents. The incident was substantiated by the facility administration based on direct contact made between the two residents.