Failure to Prevent Resident-to-Resident Physical Altercation
Penalty
Summary
The facility failed to prevent resident-to-resident abuse when two cognitively intact residents engaged in a physical altercation in one resident’s room. On 12/25/25 at 5:55 PM, two LPNs and a CNA heard yelling coming from the room of one resident and, upon entering, observed both residents in their wheelchairs hitting or punching each other. The residents were separated and assessed, and no injuries were identified. One resident later reported that the other had his music playing loudly, and after a request to turn it down was ignored, he turned the music off himself, at which point he stated the other resident hit him in the face twice, though without causing injury. The other resident reported that the first resident had been disrespectful but would not provide further detail. Staff interviews confirmed that the residents were not roommates but lived on the same hallway and that staff heard a commotion and then found both residents in their wheelchairs physically striking each other in the room, with one LPN stating she did not hear loud music prior to the incident. This sequence of events, including the escalation of a dispute over loud music into physical contact between two cognitively intact residents, and staff only becoming aware once yelling and commotion were heard, demonstrates a failure by the facility to protect each resident from abuse, specifically resident-to-resident physical abuse, as required by its abuse prevention responsibilities.
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