Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when an altercation occurred between two residents sharing a room. One resident, who had a history of moderate cognitive impairment, left femur shaft fracture, hemiplegia, hemiparesis, and a malignant brain tumor, was found sitting on the floor after being pushed by his roommate. The incident began when the first resident was rummaging through the roommate's closet, despite being told to stop. The roommate, also with moderate cognitive impairment and dementia, admitted to pushing the first resident in an attempt to stop him from going through his belongings. Multiple staff notes and interviews confirmed that the push resulted in the resident falling to the floor. The situation escalated further when the resident who was pushed attempted to retaliate with a cane, but staff intervened before any further physical contact occurred. Both residents were observed using elevated voices and profanity during the altercation, and the staff documented that the resident who pushed did so deliberately after verbal warnings were ignored. The facility's policy prohibits all forms of abuse, including the willful infliction of injury. Despite this, the incident was not prevented, and the resident was not protected from physical abuse by another resident. The deficiency was identified through observation, interviews, and record reviews, which consistently indicated that the facility did not ensure the safety of the resident involved in the altercation.