Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from abuse by other residents in two separate incidents. In the first incident, a resident with moderate cognitive impairment and a history of insomnia was physically assaulted by another resident with severe cognitive impairment and a history of physical altercations. The assault occurred when the resident with severe cognitive impairment became confused in an adjoining bathroom, exited into the wrong room, and struck the sleeping resident, resulting in a laceration above the victim's right eyelid. Staff interviews confirmed the confusion and physical altercation, and documentation indicated that the aggressor had a prior history of similar behavior. In the second incident, a resident with severe cognitive impairment and a history of physical aggression became upset when their wheelchair was blocked by another resident with moderate cognitive impairment. The agitated resident slapped the other resident in the face, knocking off their glasses and causing redness to the jaw. The incident was witnessed by a nurse aide, and the aggressor was immediately removed from the area. The victim later reported feeling unsafe in the facility as a result of the incident. Both incidents involved residents with documented behavioral and cognitive issues, and the facility's care plans noted the potential for aggression and confusion. Despite these known risks, the facility did not prevent the occurrences of resident-to-resident physical abuse, resulting in physical harm and emotional distress to the affected residents.