Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent abuse when one resident physically struck another resident. According to the facility's incident report and subsequent investigation, a resident (R1) admitted to slapping another resident (R2) on the left side of the head. This action occurred after R2 was reportedly calling certified nurse aides inappropriate names. Both residents were found to be cognitively intact, as indicated by their BIMS scores of 15. The incident was reported to the nurse on duty and subsequently to the state surveying agency. The facility's Abuse Prevention and Reporting policy prohibits abuse, neglect, and mistreatment of residents, and affirms the right of residents to be free from such actions. Despite this policy, the incident occurred when R1 confronted R2 in another resident's room and made physical contact in response to R2's verbal behavior toward staff. The facility's investigation confirmed the physical altercation and the circumstances leading up to it, demonstrating a failure to protect residents from abuse as required by facility policy.