Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident struck her on the left cheek while both were in the hallway. The incident occurred as one resident was wheeling herself in her wheelchair and was approached by another resident, who was being pushed by a CNA. The aggressor resident reached out, grabbed the victim's left arm, and punched her on the left cheek. Multiple staff members, including CNAs and nurses, witnessed or were immediately informed of the event, and documentation confirmed the physical contact and the resident's report of being hit. The resident who was struck had a history of transient cerebral ischemic attack, unspecified encephalopathy, and generalized muscle weakness. Her cognitive skills for daily decisions were moderately impaired, and she required moderate assistance for activities such as toileting and showering. The aggressor resident had diagnoses including metabolic encephalopathy, diabetes mellitus, and generalized muscle weakness, with severely impaired cognitive skills and no capacity to make decisions. Staff interviews and records indicated that the aggressor resident had a known history of aggressive behaviors, including previous incidents directed at staff. Facility policy and procedure documents, as reviewed with the Director of Nursing and other staff, clearly state that residents have the right to be free from abuse, including physical abuse by other residents. Staff interviews consistently identified the incident as abuse, regardless of the aggressor's cognitive status or the absence of physical injury. The event was substantiated by witness statements, resident reports, and facility documentation, confirming that the resident was not protected from physical abuse as required by facility policy.