Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents with severe cognitive impairment from abuse by another resident. According to staff interviews and record reviews, one resident approached another seated resident and struck her on the left cheek with an open hand. The incident was witnessed by a CNA, who reported that the resident had his hand raised and, despite being told to stop, proceeded to slap the other resident. The event was described as unprovoked, and the resident who was struck showed no visible injuries or emotional distress, but did react by holding her face. Both residents were noted to have severe cognitive impairment on their Minimum Data Set assessments. Prior to this incident, there was documentation in the progress notes that the same resident had previously walked down the hallway and hit the same resident on the face, with no explanation for his actions. Staff noted that the resident who committed the act had a history of agitation and irritability, particularly with staff, but had not previously been known to hit other residents. The facility's abuse prevention policy affirms residents' rights to be free from abuse, but the events described indicate a failure to ensure this protection.