Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse, as evidenced by two separate incidents involving physical altercations between two residents. One resident, who has severe dementia, metabolic encephalopathy, and major depressive disorder, was observed wandering the dementia unit and was involved in altercations with another resident. In the first incident, after the second resident complained to a CNA about the first resident urinating on the floor and being in their shared room, the second resident shoved the first resident on the shoulders, causing the first resident to stumble backward before being intercepted by the CNA. The second incident involved the same two residents, where the second resident was observed yelling at and then slapping the first resident on the head while the first resident was sitting on the edge of another resident's bed. Staff intervened during both incidents, but not before physical contact occurred. Documentation and interviews confirm that the second resident was aware of their actions and expressed frustration about the first resident's wandering and interference with personal belongings. The first resident, due to severe cognitive impairment, was unable to understand or respond appropriately to the situation. Staff statements indicate that the second resident deliberately struck the first resident and had previously threatened further physical harm. These events demonstrate a failure by the facility to prevent physical abuse between residents, despite awareness of the first resident's cognitive limitations and the second resident's escalating behavior.