Failure to Prevent Resident-to-Resident Physical and Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from physical and verbal abuse by another resident. One resident with moderate cognitive impairment was struck on the left elbow with a cane by a roommate who has severe cognitive impairment. The incident occurred during a verbal altercation in their shared room, where the aggressor also threatened to kill the other resident. The altercation was witnessed by an LPN who was passing medications nearby and heard yelling and cursing coming from the room. Upon entering, the LPN observed the physical assault and heard the verbal threats. The resident who was struck confirmed the incident and reported that the aggressor becomes upset and acts out when agitated, specifically mentioning concerns about a missing watch. The facility's records, including progress notes and interviews, document that the incident was reported to facility leadership and the appropriate authorities. The facility's abuse prevention policy states that residents have the right to be free from abuse, including abuse by other residents. Despite this policy, the facility did not prevent the physical and verbal abuse that occurred between the two residents, resulting in a failure to ensure a safe environment as required.