Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
Multiple incidents of resident-to-resident physical abuse occurred within the facility, involving residents with varying degrees of cognitive impairment. In one instance, a resident with severe cognitive impairment was seated in a hallway when another resident, also severely cognitively impaired, approached and deliberately slapped her in the face. The incident was witnessed by a CNA, who reported that the resident who was struck appeared to be in pain but was unable to verbalize it due to her cognitive status. Both residents involved were unable to recall the incident during subsequent interviews. Another event involved a resident with no cognitive impairment being struck by a resident with severe cognitive impairment. The altercation occurred after the cognitively intact resident asked the other to move out of the way, resulting in the latter hitting her with a book. Witnesses confirmed the physical contact, and the resident who was struck reported minor pain but no lasting injury. The aggressor was described as often paranoid and confused, with a history of making accusatory remarks toward others. Additional incidents included a resident with severe behavioral symptoms hitting another resident on the head with a bingo card during an activity, and a resident grabbing another's wrist after a minor dispute over a dropped fork. In each case, the aggressors and victims had varying levels of cognitive impairment, and some were unable to recall the events. Facility staff observed and intervened in these altercations, and skin assessments were performed to check for injuries. The facility's policy defines abuse as any willful infliction of injury or pain, regardless of cognitive status, and requires all such incidents to be investigated and reported.