Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect two residents from physical abuse by other residents. In the first incident, a resident with schizophrenia and moderate cognitive impairment (BIMS score of 10) was observed by a licensed nurse standing over another resident with Parkinson’s disease and moderate cognitive impairment (BIMS score of 10) and punching him while the victim lay in bed. The nurse confirmed that the punches made physical contact with the resident’s body, though he could not specify the exact locations. This altercation occurred in the victim’s room during a medication pass. In the second incident, a resident with schizoaffective disorder and severe cognitive impairment (BIMS score of 7) struck another resident who had hemiplegia/hemiparesis and was cognitively intact (BIMS score of 13). The cognitively intact resident was seated in a wheelchair while the aggressor was standing and talking on the phone with his mother. According to one licensed nurse, the aggressor suddenly swung around, used his right arm, and struck the wheelchair-bound resident in the right eye in a punch-like motion. Another licensed nurse present reported that the aggressor abruptly hung up the phone, turned toward the other resident, and the victim then stated, “He hit me.” The facility’s own Abuse Prevention Program policy states that residents have the right to be free from abuse, including physical abuse, but these incidents of resident-to-resident physical contact occurred nonetheless.
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