Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from verbal and physical abuse between residents, as evidenced by two separate incidents involving three residents. In the first incident, a resident with severe cognitive impairment and dementia (BIMS score 3/15) was involved in a verbal altercation with another resident who was cognitively intact (BIMS score 15/15) and had a history of behavioral symptoms. The cognitively intact resident was observed yelling threatening statements, while the cognitively impaired resident pushed a medication cart toward him, resulting in the latter losing balance and sustaining a bruise and abrasion after falling. In the second incident, a resident with moderate cognitive impairment and dementia (BIMS score 9/15) was found hitting the same severely cognitively impaired resident in the face. The aggressor believed the other resident was in his bed, and this event was discovered when a CNA responded to the victim's calls for help. The incident was reported to law enforcement, and the aggressor had a recent medication change that may have contributed to impulsive behavior. Both incidents were confirmed by the DON as instances of physical and verbal abuse between residents.