Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. On 6/2/25, a certified nursing assistant (CNA) witnessed one resident physically striking another with a closed fist, resulting in a skin tear and bruising. The resident who was struck had severe cognitive impairment and was unable to provide detailed information about the incident. The aggressor also had severe cognitive impairment, a history of delusions, physical aggression, and was receiving psychiatric services and antipsychotic medication, which had recently been reduced. Prior to the incident, there were multiple documented episodes of physical and verbal aggression by the aggressor toward both staff and other residents, including swinging at residents and physically assaulting staff during care. These behaviors were noted in nursing and medication administration records. Despite these documented behaviors, there was no evidence that the physical aggression incidents were consistently reported to a physician or provider prior to the altercation. Staff interviews revealed uncertainty about whether such behaviors were communicated to psychiatric providers, and documentation of these reports was lacking. The facility's policy states that residents have the right to be free from abuse, including abuse from other residents, but the failure to report and address escalating behaviors contributed to the incident of resident-to-resident abuse.