Failure to Prevent Resident-to-Resident Physical Abuse Incidents
Penalty
Summary
The facility failed to protect residents from physical abuse during two resident-to-resident altercations involving residents with dementia and moderate to severe cognitive impairment. Facility policy on Abuse, Neglect and Exploitation, last reviewed in 06/2025, defined abuse as the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish, and specified that physical abuse includes hitting, slapping, punching, biting, and kicking, and can include certain resident-to-resident altercations. Despite this policy, two separate incidents occurred in which residents made physical contact with other residents in a manner that staff and leadership later characterized as physical abuse. In the first incident, on 10/02/2025, a resident with dementia and agitation, and a BIMS score of 9/15 indicating moderate cognitive impairment, was waiting for a smoke break when another resident with Alzheimer’s disease and a BIMS score of 11/15 backed a wheelchair into the first resident. The first resident then reached out with an upper extremity, swatted, and made contact with the other resident’s chest. An Activities Assistant who witnessed the event reported that the resident placed a hand on the other resident’s shoulder as if to signal her to stop backing up, but based on her training and experience, she considered what she witnessed to be physical abuse. The DON, who was not present at the time, later stated she felt the incident rose to the level of physical abuse, and the Administrator stated she expected residents to be free of abuse and kept safe. In the second incident, on 10/27/2025, the same resident with dementia and agitation, who had a care plan problem statement initiated on 10/02/2025 for episodes of increased aggressive behavior toward others, was involved in a verbal disagreement in the center hallway with another resident diagnosed with dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and who had a BIMS score of 3/15 indicating severe cognitive impairment. A CNA heard yelling, rounded the corner, and witnessed the second resident forcefully hit the first resident in the left shoulder, after which the first resident yelled, “Don’t you [expletive] hit me.” The CNA stated that, based on her abuse training, she considered the action to be physical abuse. The DON also stated she felt this incident rose to the level of physical abuse, and reiterated her expectation that residents be free from abuse and feel safe in the facility.
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