Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to follow its abuse prevention policy, resulting in a physical altercation between two residents. One resident, who uses a walker and has a BIMS score indicating severe cognitive impairment, was seated in the dining room when another resident, who propels himself in a wheelchair and is cognitively intact, moved the first resident's walker to create more space. In response, the resident with the walker struck the other resident in the face. Staff observed the incident, but the altercation occurred before they could intervene. Both residents were assessed after the incident, and no injuries were found. The resident who initiated the physical contact has a history of behavioral symptoms, including physical aggression and verbal outbursts when agitated, as documented in his care plan. His diagnoses include mild intellectual disabilities, schizoaffective disorder, and major depressive disorder. The other resident involved has significant medical conditions, including mantle cell lymphoma and generalized anxiety disorder, and was unable to recall the incident. The facility's policy affirms residents' rights to be free from abuse, but the policy was not effectively implemented to prevent this resident-to-resident physical abuse.