Failure to Prevent Physical Abuse Between Residents
Penalty
Summary
The facility failed to protect two residents from physical abuse, as required by its abuse prevention policy. One resident with severe cognitive impairment and a history of dementia, agitation, and behavioral disturbance was observed by staff holding another resident by the collar and punching him in the back of the head while yelling. This incident occurred in a common area and was witnessed by two LPNs, one of whom described seeing the altercation upon entering the kitchen, and another who observed the event during breakfast in the dining room. The facility's records confirm that the resident who initiated the altercation had a care plan noting impaired cognitive function, while the other resident involved was cognitively intact but had a documented history of aggressive behavior and threats toward staff. The facility's abuse policy, which strictly prohibits any form of abuse, was not effectively implemented in this case. Documentation and staff interviews confirm that the physical altercation occurred, and the administrator acknowledged awareness of the incident but was unable to provide an explanation for its cause. The failure to prevent this altercation resulted in a violation of the residents' right to be free from physical abuse.