Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Human Bite
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident entered his room and bit him on the hand. Resident 1 had been admitted in November 2025 with diagnoses including diabetes mellitus, difficulty walking, and morbid obesity, and had a BIMS score of 15, indicating no memory impairment. Resident 2 was admitted in December 2025 with vascular dementia and anxiety disorder and had a BIMS score of 1, indicating severe memory impairment. On 1/13/26, Resident 1’s SBAR form documented that Resident 2 wandered into Resident 1’s room, was confused and angry, and bit Resident 1 on the right hand, resulting in impaired skin integrity and risk for pain, discomfort, and infection. On the day of the incident, a licensed nurse observed Resident 2 in the hallway in disarray and called for a CNA to assist Resident 2 back to his room. The CNA was occupied assisting another resident when the nurse heard Resident 1 call out, “He bit me.” The nurse then went to Resident 1’s room, removed Resident 2 from the room, and later assessed Resident 1, observing obvious bite marks with droplets of blood on his hand. In a subsequent interview, Resident 1 reported that he had been in bed when Resident 2 charged toward him, stated “I’m going to kill you and I hate you,” then punched and bit him. The facility’s abuse prevention policy states that residents have the right to be free from abuse, but this incident occurred despite that policy.
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