Failure to Protect Resident From Physical and Verbal Abuse by Co-Resident
Penalty
Summary
The facility failed to protect a cognitively intact resident from physical and verbal abuse by a co-resident. Resident 1, admitted with COPD and documented as having intact cognition with a BIMS score of 15/15, reported that on the evening of 2/14/26 she was accused of stealing Resident 2’s stuffed animal. According to Resident 1 and an SBAR Communication Form dated 2/14/26, Resident 2 scratched and kicked Resident 1 during this altercation. An SBAR for Resident 2 on the same date documented that Resident 2 was involved in a physical and verbal altercation with Resident 1. On observation several days later, Resident 1 had a scabbed wound approximately 1/8 inch in length with surrounding redness on her right arm, which she stated resulted from Resident 2’s fingernail when Resident 2 grabbed her arm in the foyer while swinging the stuffed animal at her. Resident 2, who had dementia and a severely impaired BIMS score of 3/15, was observed and described by staff as engaging in both physical and verbal aggression toward Resident 1. An LPN (LN 2) reported that between 7:30 p.m. and 8 p.m. on 2/14/26, while charting at the nurse’s station near the foyer, he heard the two residents arguing and saw Resident 2 swing a stuffed animal at Resident 1 while cussing at her, with Resident 1 using her arm to block the blow. Resident 1 later stated that after they were separated, Resident 2 waited for her in their shared room, kicked her right leg, continued cussing, and threatened to kill her. Another nurse (LN 1) stated that around 9:30 p.m. that same night, she heard yelling from the room and heard Resident 2 threaten Resident 1, telling her to get out of the room and stating, “I want to kill you.” These events occurred despite the facility’s written Abuse Prevention Program policy, which states residents have the right to be free from verbal and physical abuse and that residents must be protected from abuse by anyone, including other residents.
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