Failure to Prevent Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse when they engaged in a physical altercation with each other. One resident, who was cognitively intact with a BIMS score of 13/15, reported that another resident hit him on the head with a closed fist, causing pain to his right hand and left ear and leaving him feeling fearful and unsafe in the facility. The other resident involved had severe cognitive impairment, with a BIMS score of 4/15, and later stated he had no recollection of the altercation. Progress notes documented that a third resident witnessed the incident and alerted nursing staff that the two residents were facing one another in their wheelchairs on the patio, hitting each other and yelling profanities. Nursing notes indicated that the cognitively intact resident sustained a cut on his right knuckle and complained of pain in his left ear. Social services documentation showed that this resident acknowledged striking the other resident and justified his actions by stating he felt frustrated. These events occurred despite the facility’s Abuse Prevention Program policy, which states that the administrator will protect residents from abuse by anyone, including other residents.
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