Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving two residents with severe cognitive impairment and dementia. One resident, who had a history of accusatory statements, verbal aggression, and misperceptions related to Alzheimer's disease, became agitated after observing another resident speaking with a female peer. Due to her cognitive impairment and delusional belief that the other resident was her deceased husband cheating on her, she attempted to strike him on the cheek, making contact with her fingertips. Staff immediately intervened and separated the residents, and both were assessed with no injuries noted. Interviews with staff and documentation confirmed that both residents involved were confused and cognitively impaired. The incident occurred in a common area near the nurse's stations, where the aggressor approached and made contact with the other resident's cheek. The facility's abuse policy prohibits all forms of abuse, neglect, and mistreatment, but the event demonstrated a failure to prevent physical abuse between residents, as required by regulation.