Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, as evidenced by an incident involving resident-to-resident physical abuse. One resident, who had a history of anxiety, cerebral infarction, and recent suicidal ideation, exhibited escalating behaviors including threats of self-harm and confrontational interactions with nursing staff regarding pain medication. Despite these documented behaviors and changes in mood, the resident was not effectively monitored or managed to prevent harm to others. This culminated in an incident where the resident physically assaulted another resident, resulting in facial bruising, laceration, and redness to the eye and nose area. The assaulted resident had a history of Parkinson's disease and dementia but was assessed as having no cognitive impairment at the time. The facility's failure to prevent this abuse constituted a violation of the resident's rights and placed all residents at risk for ongoing abuse and potential harm.