Failure to Prevent Resident-to-Resident Physical Abuse During Hallway Argument
Penalty
Summary
The facility failed to protect residents from physical abuse when one resident struck another during an argument. The facility’s Abuse Prohibition policy, revised on 8/25/25, affirms that all residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, and exploitation. Despite this policy, an incident occurred in which two residents who were sitting in the hallway talking began to argue, and one resident hit the other on the arm. A witness reported seeing the resident raise a hand and smack the other resident on the arm after becoming upset during the disagreement. The residents involved both had significant cognitive and functional impairments documented in their medical records and MDS assessments. One resident had diagnoses including fibromyalgia, dementia without behavioral disturbances, and psychosis, was severely cognitively impaired, exhibited physical/verbal behavioral symptoms one to three times a week, used a wheelchair for mobility, and required substantial to maximum assistance with all ADLs. The other resident had diagnoses including lumbar spinal stenosis without neurogenic claudication and delusional disorders, was also severely cognitively impaired, exhibited physical/verbal behavioral symptoms one to three times a week, used a wheelchair, and required substantial to maximum assistance with ADLs. The incident in which one resident hit the other on the arm, as confirmed by a witness and the Administrator, represents a failure to uphold the facility’s abuse prohibition policy and to protect residents from physical abuse by another resident.
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