Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
A resident with a history of psychoactive substance abuse, bilateral blindness, and hallucinations, who was identified as moderately cognitively impaired and at risk for abuse or neglect, was involved in a physical altercation with another resident. The incident occurred outside the facility, where an argument escalated, resulting in one resident being hit in the groin and subsequently slapped in the face by the other. Staff members, including a CNA and two LPNs, witnessed or were informed of the altercation and intervened to separate and assess the residents. The event was documented in the resident's progress notes and reported to facility administration and the police. The facility's abuse prevention policy emphasizes the establishment of a resident-sensitive and secure environment to prevent abuse and neglect. Despite this policy, the incident demonstrates a failure to prevent resident-to-resident abuse, as the altercation occurred and physical contact was made before staff intervention. The involved resident's care plan had previously identified them as being at risk for abuse or neglect, yet the measures in place were insufficient to prevent the incident.