Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and a mental health condition was physically abused by another resident. The incident took place during a smoke break, when the first resident, while maneuvering his wheelchair, accidentally rolled over the other resident's foot. In response, the second resident slapped the first resident on the left cheek, causing immediate pain rated as 8 out of 10. The event was witnessed by a mental health worker, who reported hearing a loud slapping sound and observed the affected resident holding his face in pain. The incident was also confirmed by the Director of Nursing, who acknowledged that staff were present at the time but failed to prevent the altercation. The affected resident reported feeling unsafe and disrespected as a result of the incident. Facility records and interviews confirmed that the altercation was witnessed by staff, and that the facility's policies require protection of residents from abuse, including abuse by other residents. Despite these policies and staff presence, the facility failed to prevent the physical abuse, resulting in both physical and emotional harm to the resident.