Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Harm
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. One resident with severe cognitive impairment and physical dependency was struck on the right lower leg by another resident's cane, resulting in a bruise. The incident occurred when the resident was being assisted to the bathroom by a CNA, and the other resident, who had a history of physical and verbal behaviors directed at others, approached, yelled, and swung the cane. Documentation confirmed the injury, and both residents acknowledged the contact, with the aggressor initially denying but later admitting to the action. Staff interviews revealed uncertainty about whether the altercation was directly witnessed, but the injury was observed and reported. The facility's incident report and medical assessments documented the event and the resulting harm. The facility's policy states that all residents will be protected from abuse and neglect, but the incident demonstrated a failure to prevent resident-to-resident physical abuse, resulting in actual harm.