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. According to facility records and staff interviews, one resident with severe cognitive impairment and a history of psychosocial well-being issues was involved in a physical altercation with their roommate, who also had severe cognitive impairment, dementia, and a history of behavioral problems including aggression and poor impulse control. The incident occurred when the aggressive resident entered the other resident's bed and began fighting over a pillow, resulting in a skin tear on the affected resident's forearm. Staff observed the altercation and noted that the aggressive resident had their fingernails in the other resident's arm during the incident. Both residents had documented histories of cognitive impairment and behavioral concerns, with care plans indicating risks for negative interactions and physical behaviors. Progress notes and staff interviews confirmed that the altercation was witnessed by an LPN, who intervened to separate the residents. The facility's policies prohibit all forms of abuse and require recognition and prevention of such incidents, but the altercation still occurred, resulting in physical harm to one resident.