Failure to Prevent Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse when multiple resident-on-resident altercations occurred involving cognitively impaired residents with known behavioral histories. In one incident, a male resident with unspecified and vascular dementia, severe cognitive impairment, restlessness, agitation, generalized muscle weakness, osteoarthritis, wandering and exit-seeking behaviors entered the room of a female resident with severe cognitive impairment, psychotic disorder, major depressive disorder, generalized anxiety, glaucoma, and cognitive communication deficit. The female resident reported that the male resident repeatedly came into her room and would not leave, and that she scratched and grabbed him while trying to pull him out of her room, after which he punched her in the chest. A CNA responded to screams and witnessed the male resident strike the female resident in the chest, and an LPN later confirmed being informed that the male resident, who had a history of wandering, agitation, and difficulty with redirection, had punched the female resident while she was trying to shove him out of her room. Social services staff acknowledged that the male resident had a history of wandering and aggressive behaviors and that he should be monitored when out of his room, and also noted that the female resident had dementia, confusion, and a history of past abuse experiences. In a separate incident, the facility did not prevent physical abuse when one female resident with vascular dementia with behavioral disturbances, unspecified psychosis, muscle weakness, cognitive communication deficit, and a history of verbal and physical aggression struck another female resident with dementia, anxiety, insomnia, GERD, rheumatoid arthritis, and spinal stenosis. While a nurse was passing medications in the dining room, the victim resident reported that another resident had hit her in the face after becoming upset about wanting to sit at the same table when there was no room. The nurse observed immediate bruising and later dark purple discoloration to the left side of the victim’s face. Another resident at the table corroborated that the aggressive resident approached in a wheelchair, demanded the victim’s seat, and, after being told no, punched her in the eye, causing pain and a black eye. This witness also stated that the aggressor had a “mean streak” and prior verbal altercations with staff and residents. The administrator, serving as abuse coordinator, confirmed that the incident involving the two residents in the first event was witnessed and that physical abuse was substantiated. The facility’s abuse policy affirms residents’ rights to be free from abuse and defines physical abuse as the infliction of injury by non-accidental means, including hitting and similar acts.
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