Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when one resident with dementia and agitation pulled on another resident's indwelling catheter while the latter was sleeping. The incident occurred when a CNA heard the cognitively intact resident yelling and entered the room to find the confused resident holding the catheter urine collection bag, which had been forcibly removed. The resident who experienced the abuse reported severe pain during and after the incident, and staff interviews confirmed the resident was in significant distress for several days following the event. The facility's abuse policy defines physical abuse as the willful infliction of injury resulting in harm, pain, or mental anguish, and requires residents to be protected from such abuse. Multiple staff members recalled the incident, describing the resident's pain and emotional distress, and noted that the resident with dementia was confused at the time. The incident report and staff interviews confirmed that the resident's catheter tubing was broken off during the event, causing ongoing pain and requiring staff support until the resident received pain medication.