Failure to Protect Resident From Physical Abuse by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. One resident with encephalopathy, schizoaffective disorder, anxiety disorder, and severe cognitive impairment was originally admitted on 3/1/2025 and required set-up assistance with eating, oral hygiene, and personal hygiene. Another resident, admitted on 9/24/2025 with encephalopathy, heart failure, dementia, schizoaffective disorder, mood disorder, anxiety disorder, and severe cognitive impairment, required supervision with eating, partial assistance with oral hygiene, and substantial assistance with personal hygiene, showering, and toileting hygiene. Both residents had significant cognitive and functional impairments at the time of the incident. According to CNA 1’s written statement and interview, the aggressor resident was standing on the left side of the other resident’s bed while the victim was lying in bed. The aggressor kicked the resident on the left side of the body, then kicked again, causing the resident to roll off the bed and fall onto the floor mat on the right side. CNA 1 attempted to intervene but was pushed away by the aggressor and then called for help. During this time, the aggressor reached for and threw a water pitcher, with the pitcher and water landing on the resident’s face, and then grabbed and threw a urinal filled with urine, which landed on the resident’s chest. Nursing documentation on 1/26/2026 at 2:15 p.m. indicated the resident had been hit by another resident and presented with slight swelling of the left temporal area, redness on the left shin, right knee, and chest, and responded to name by saying yes or moaning. Emergency Department records later that evening documented a left maxillofacial contusion after being hit in the face. LVN 2 reported hearing calls for help, finding the victim resident on all fours on the fall mattress, the aggressor pacing and stating, “I beat him up,” and observing fluids (water and urine) on the floor and on the resident. The DON stated that residents have the right to be free from abuse, acknowledged that the aggressor physically abused the other resident, and stated that staff should have physically separated the residents after the first kick to prevent the subsequent kicks and the throwing of the water pitcher and urinal.
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