Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with moderately impaired cognition was physically abused by another resident with intact cognition. The incident took place in a shared room, where a certified nursing assistant (CNA) observed one resident standing beside the other, making closed fist contact with the resident's chest while the latter was lying in bed. The assaulted resident sustained a minor laceration to the upper lip, which was confirmed by a licensed nurse upon assessment. The resident who committed the act admitted to being provoked by something the other resident said. The facility's policy and procedures on abuse prevention state that residents have the right to be free from abuse, including physical abuse, and that the administration is responsible for protecting residents from abuse by anyone, including other residents. Despite these policies, the facility failed to prevent the physical abuse, resulting in injury to the resident. Interviews with staff and both residents confirmed the occurrence of the incident and the resulting injury.