Failure to Protect Resident from Peer-to-Peer Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when another resident with a history of schizophrenia and severe cognitive impairment poured water on her face while she was receiving assistance with activities of daily living (ADLs). The affected resident, who was dependent on staff for ADLs and had intact cognition, reported feeling like she was drowning as the water covered her face and entered her mouth and throat. Witnesses, including another resident, described the act as intentional and distressing, and noted that staff were present in the room during previous verbal altercations between the two residents. The certified nursing assistant (CNA) providing care to the affected resident had left the room briefly, during which time the incident occurred. Upon returning, the CNA found the resident crying and soaked, and was informed of the water being poured. The CNA also reported prior incidents of conflict between the two residents, including verbal aggression and disputes over personal belongings. The Director of Nursing (DON) was unaware of the incident at the time of the interview but acknowledged that such an act would be considered abuse according to facility policy, which states that residents must not be subject to abuse by anyone, including other residents.