Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. One resident, who had a documented history of physical and verbal aggression, psychiatric and cognitive impairments, and was not cognitively intact, made physical contact with another resident's upper thigh while the second resident was lying in the first resident's bed. Staff interviews confirmed that the aggressive resident frequently attempted to grab or reach for other residents and had previously been physical with others. The care plan for the aggressive resident noted ongoing issues with ineffective coping and aggression related to cognitive impairment. Despite these known behaviors and risks, the facility did not prevent the incident of physical abuse, as documented in the facility's abuse report and confirmed by staff and administrative interviews.