Failure to Prevent and Document Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse involving a resident with moderate cognitive impairment and mild intellectual disabilities. According to the comprehensive cognitive assessment, this resident required total assistance with transfers and had limited use of her right arm due to hemiplegia/hemiparesis. Incident investigation reports and interviews revealed that the resident stated her roommate had hit her "all over," although she denied being physically hurt. The roommate, who was independent with mobility and had a history of manipulative and rude behavior toward past roommates, denied hitting the resident but stated that if she did, it was unintentional. Documentation showed that the two residents were roommates until one was moved to another room, with the move attributed to roommate preferences and behavioral concerns. Staff interviews indicated that there were reports and gossip among staff about the alleged physical altercation, with some staff recalling hearing that one resident was on the other's bed and may have hit her. However, there was no documentation in the progress notes regarding the potential physical altercation or the behavioral incidents leading up to the room change. The facility's policy prohibits abuse, neglect, and exploitation, including physical abuse such as hitting, slapping, and punching, but the lack of documentation and follow-up on the reported incident demonstrates a failure to fully investigate and address the alleged abuse.