Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by other residents, resulting in actual harm to two residents with severe cognitive impairment. In one incident, a resident with Alzheimer's disease and severe cognitive impairment was found outside a staff bathroom, yelling obscenities and accusing another resident of pinching them. The accused resident was found with their hands near the complainant's neck, and staff observed a 0.6 cm open wound on the neck of the resident who reported being pinched. The wound was cleaned and dressed by nursing staff. In another incident, a resident with moderate cognitive impairment and a history of verbal aggression struck a severely cognitively impaired resident in the face with a spiral notebook. The victim was visibly upset and cried, asking why the assault occurred. Approximately 30 minutes later, the same aggressor pulled a clump of hair from the victim's head, requiring intervention by two staff members to separate them. The victim was again distressed and refused further care related to hair grooming for the remainder of the night. Staff interviews confirmed that these incidents were witnessed and that the aggressors were separated from the victims following the events. The facility's policy on abuse, which defines abuse as including physical abuse and mistreatment of vulnerable adults, was reviewed as part of the investigation. The incidents demonstrate a failure to prevent resident-to-resident physical abuse, resulting in physical and emotional harm to the affected residents.