Failure to Protect Residents From Repeated Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical abuse by other residents, despite a policy stating residents have the right to be free from abuse and neglect and must be protected from abuse by anyone, including other residents. One resident with schizophrenia, major depression, anxiety disorder, and moderate cognitive impairment (BIMS 10/15) was slapped on the back of the head by another resident with schizophrenia, memory loss, and severe cognitive impairment (BIMS 3/15), as witnessed by a CNA; the victim later reported feeling upset. In another incident, a resident with schizophrenia and intact cognition (BIMS 13/15) was documented as striking his roommate, a resident with schizophrenia, need for assistance with personal care, and moderately impaired cognition (BIMS 12/15), while appearing highly psychotic, unable to follow directions, and aggressive toward staff. The roommate later stated he was punched in the face while in bed and felt scared, and a CNA reported seeing punches thrown. Additional incidents included a resident with schizophrenia and need for assistance with personal care, with intact cognition (BIMS 13/15), entering the room of the same moderately cognitively impaired resident, who then struck him in the face, causing a mild tear and slight bleeding of the lip; the aggressor later confirmed hitting the other resident on the lip. In a separate event, a resident with schizophrenia, restlessness, agitation, and severe cognitive impairment (BIMS 6/15) engaged in a verbal altercation with another resident with schizophrenia, difficulty walking, memory problems, chronic pain syndrome, and moderate cognitive impairment (BIMS 10/15), which escalated to the first resident pushing the second. The pushed resident reported being shoved on the shoulders, falling to the ground, and experiencing back and leg pain, and a CNA confirmed witnessing the intentional push that caused the fall. The DON stated her expectation that all residents be free from abuse and safe in the facility, but the documented resident-to-resident assaults demonstrate that residents were not protected from physical abuse as required by facility policy.
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