Failure to Protect a Cognitively Impaired Resident From Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in injury. Resident 1, who had a severely impaired cognition with a BIMS score of 3 out of 15 on the 11/14/25 MDS, was involved in a resident-to-resident altercation with Resident 2. Resident 2 had moderately impaired cognition with a BIMS score of 8 out of 15 on the 8/19/25 MDS, and the MDS Section E documented physical behavioral symptoms directed toward others occurring one to three days out of seven, including behaviors such as hitting, kicking, pushing, scratching, grabbing, or sexually abusing others. Staff interviews indicated that Resident 2 was easily agitated, sometimes irritated by other residents, and often required separation from others. The DON stated Resident 2 had good and bad days due to dementia, could be easily upset by various disturbances, and had prior behavior problems related to a need for medication adjustment. On 8/12/2025 at 10:15 a.m., an incident summary documented a resident-to-resident altercation between Resident 1 and Resident 2. A CNA observed Resident 2 swinging a coffee cup toward Resident 1's head, which resulted in Resident 1 sustaining a blue-purple bump with discoloration on the right frontal area of the head and a cut on the upper lip. Prior to this, on 1/28/26 at 11:24 a.m., Resident 1 had been observed sitting in a wheelchair outside the room with no discoloration or wounds noted on the face, indicating the injuries were associated with the altercation. The Administrator, who also served as the abuse coordinator, stated that Resident 2 was typically upset or agitated about anything and required communication or talking down to diffuse behavior, and that specific CNAs and Social Services staff were very familiar with Resident 2’s behavior and need for redirection. Despite the facility’s written Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy dated April 2021, which required protection of residents from abuse by anyone including other residents, Resident 1 was not protected from physical abuse by Resident 2.
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