Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. On the date of the incident, a resident with unspecified dementia, psychotic disturbance, anxiety disorder, and bilateral conductive hearing loss was sitting at a dining room table, feeling his surroundings due to blindness. As he touched a package of graham crackers on the table, another resident with bipolar disorder, severe vascular dementia with psychotic disturbance and agitation, major depressive disorder, and anxiety disorder became upset. The certified nursing assistant (CNA) attempted to intervene by removing the first resident from the table and positioning herself between the two residents. Despite this, the second resident went around the CNA, confronted the first resident, yelled, and slapped him on the left side of the face, resulting in a visible red mark and a reported pain level of 4. Staff interviews confirmed that the CNA and a licensed practical nurse (LPN) were present during the incident. The CNA described her attempt to prevent the altercation by physically intervening, but was unable to stop the aggressive resident from reaching and striking the other resident. The LPN and the assistant director of nursing (ADON) both acknowledged awareness of the incident and confirmed that the resident was not protected from abuse. The facility's own policy states that residents must not be subjected to abuse by anyone, including other residents, but this policy was not effectively implemented in this case.