Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident, as evidenced by a documented physical altercation between two individuals. One resident, who had diagnoses including End Stage Renal Disease, Chronic Diastolic Heart Failure, Type Two Diabetes Mellitus, Hypertensive Heart and Chronic Kidney Disease with Heart Failure, and Stage Five Chronic Kidney Disease, reported being grabbed and punched in the arm by her roommate during a dispute over a shirt. The resident sustained a bruise on her arm as a result of the incident and responded by hitting the other resident back and throwing a glass of water in an attempt to stop the altercation. The other resident involved, who had moderate cognitive impairment and diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction, Hyperlipidemia, and COPD, also confirmed the altercation but denied being harmed. The incident was corroborated by interviews and record reviews, which indicated that the altercation was initiated over a personal belonging and escalated to physical violence. The care plan for the resident with cognitive impairment had previously addressed physical aggression towards other residents. The facility's abuse policy requires protections to prevent abuse, neglect, and exploitation, including resident-to-resident altercations, but the occurrence of this event demonstrates a failure to prevent physical abuse between residents.