Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. According to the facility's policy, all residents are to be protected from abuse, including physical abuse, and any alleged incidents must be immediately investigated with measures taken to protect the alleged victim. On the date of the incident, two residents with severe cognitive impairment and behavioral disturbances were observed at the nurses' station when one resident slapped the other as he moved in front of him. The second resident responded by slapping back with his fist. Both residents were separated and assessed, with no apparent injuries noted. The facility's documentation and investigation confirmed that the altercation was witnessed and reported to the state agency. The incident involved residents with diagnoses such as Alzheimer's disease, dementia with agitation, and delusional disorders. Despite the facility's policy requiring immediate protection and increased supervision of residents during such incidents, the altercation occurred, indicating a failure to prevent physical abuse between residents. Staff interviews were limited due to the time elapsed since the incident, and no lingering psychosocial effects were noted for either resident.