Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two severely cognitively impaired residents from physical abuse by each other on two separate occasions. One resident, admitted in 2021 with a BIMS score of 3/15 and dependent on staff for ADLs, approached another resident in the dining room and asked an LPN to take the other resident outside and kill her. After being verbally redirected and moved away, the resident wheeled herself back, kicked the other resident’s wheelchair, and later pulled the other resident’s hair and would not let go until staff intervened. Staff documented that the resident had no behaviors directed to self or others on the most recent MDS assessment prior to this event. The other resident, admitted in 2022 with a BIMS score of 1/15 and also documented as having no behaviors on the most recent MDS, later initiated a separate altercation in the dining room. During this incident, the resident approached the first resident, intentionally pinched the back of her hand, and attempted to run over her feet with a wheelchair. Staff witnesses, including CNAs, described these actions as intentional and confirmed that the involved resident was crying as a result. Social services staff and the Administrator acknowledged that both resident-to-resident altercations constituted abuse under the facility’s policy, which states that residents will not be subjected to abuse by anyone, including other residents.
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