Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent abuse when one resident threw a pitcher of water at another resident. Resident 1, who had a history of respiratory failure, hemiplegia, hemiparesis following a stroke, and major depressive disorder, was assessed as having moderately intact cognition. Resident 2, who had a history of stroke, anxiety disorder, and aphasia, was assessed as having intact cognition. According to documentation, Resident 2 became agitated by what he perceived as excessive noise from Resident 1 and responded by throwing water at him. Resident 1 was surprised by the incident and did not realize his behavior was agitating his neighbor. Interviews confirmed that Resident 2 admitted to throwing water on Resident 1 due to ongoing frustration with the noise and a perceived lack of intervention by staff. The facility's policy on abuse prevention states that residents have the right to be free from abuse, including abuse by other residents. The incident demonstrates a failure to protect Resident 1 from abuse as required by facility policy.