Failure to Prevent Resident-to-Resident Physical Abuse in Shared Room
Penalty
Summary
The facility failed to protect a resident from abuse by another resident in accordance with its abuse prevention policy. On January 11, 2026, two residents who were friends and shared a room were involved in an altercation in their shared room. One resident (R8), who had diagnoses including major depressive disorder severe with psychotic symptoms, alcohol and cocaine abuse, COPD, and asthma, returned from a community pass appearing anxious and talking loudly. The other resident (R5), who had diagnoses including major depressive disorder, COPD, history of malignant neoplasm of the breast, history of healed femur fracture, history of alcohol abuse, cannabis abuse, and anxiety disorder, approached the bathroom doorway in an attempt to calm R8. As R8 exited the bathroom, R8 pulled R5’s hair and hit R5 on the forehead without provocation. R5 reported being surprised and upset by R8’s actions and immediately left the room to seek staff assistance. R5 stated that there was no injury from the incident. The Administrator confirmed that the incident between the two residents was substantiated as abuse, with R8 identified as the perpetrator and R5 as the victim. The facility’s own Abuse Prevention and Reporting policy, dated February 2, 2026, affirms residents’ rights to be free from abuse and to have an environment that promotes resident safety and security. Despite this policy, the incident occurred, resulting in a substantiated finding of abuse involving one of the residents reviewed for abuse in the survey sample.
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