Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by two separate incidents in which one resident physically assaulted another. Both residents involved had diagnoses of dementia and were cognitively impaired, as indicated by low BIMS scores. In the first incident, one resident was observed hitting the other with a cane in the activities room, following a verbal exchange. Staff intervened, separated the residents, and conducted assessments, but no injuries were noted. In the second incident, after another verbal altercation, the same resident struck the other with a broom, causing the victim to fall and require evaluation at the emergency room. Again, both residents were assessed, and no injuries were noted for the aggressor. Despite the facility's policy prohibiting abuse and requiring protection of residents, law enforcement was not contacted after either incident. The DON stated that police were not called due to the residents' dementia diagnoses and prior experiences with law enforcement. The administrator later confirmed that police should have been notified and was unaware that this had not occurred. Staff had been trained on abuse prevention, and efforts were made to keep the residents separated, but these measures were not consistently effective, and the incidents recurred.