Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to follow its abuse prevention policy, resulting in one resident sustaining physical injuries from another resident. Both residents involved had significant cognitive impairments and were assessed as high risk for abuse, with diagnoses including dementia, Alzheimer's disease, and delusional disorder. On the morning of the incident, a nurse found one resident standing next to the other's bed holding a pillow, with the injured resident displaying new lacerations to the forehead and swelling to the left eye. Staff interviews confirmed that the injured resident had no visible injuries earlier that morning, and the aggressor was observed to be confused and unable to explain his actions. The facility's policy requires an environment free from abuse, including physical harm inflicted by others. Despite both residents being identified as high risk for abuse, the incident occurred in a shared room without apparent preventive measures in place to separate or monitor them more closely. The injured resident was non-verbal and fully dependent on staff for care, further increasing vulnerability. The failure to prevent this altercation directly resulted in physical harm to the resident.