Failure to Protect Residents from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect residents from physical abuse by another resident, resulting in actual harm to two residents with severe cognitive impairment. In one incident, a resident with dementia and a BIMS score indicating severe cognitive impairment was grabbed by another resident while attempting to take their food tray, resulting in visible bruising and redness on the arm. This was observed by a CNA and confirmed by an RN who assessed the injuries. The facility's investigation and interviews confirmed the occurrence of the incident. In a separate incident, another resident with severe cognitive impairment, non-traumatic brain dysfunction, and dependent on staff for transfers, was found yelling for another resident to leave their room. A CNA responded and found the aggressive resident leaning over the affected resident, who had a red mark on their cheek and reported being slapped. The incident was confirmed through staff interviews and facility investigation. Both incidents demonstrate a failure to ensure residents' right to be free from physical abuse as outlined in the facility's abuse prevention policy.