Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident’s right to be free from abuse when one resident physically struck another resident in the face. Resident 1, who had dementia with agitation and anxiety and a BIMS score of 10/15 indicating moderately impaired cognition, had a care plan revised on 6/21/25 that identified psychosocial/behavioral symptoms including striking out, grabbing others, and being verbally or physically abusive to staff and patients, with a goal that emotions would be controlled so as not to result in injury to self or others. On 2/22/26, facility staff witnessed Resident 1 hit Resident 4 in the face during an altercation between the two residents. Resident 4 had diagnoses including bipolar disorder, anxiety, major depressive disorder, and parkinsonism. Following the incident on 2/22/26, Resident 4’s progress note documented that the resident verbalized sadness and anger about the situation and appeared tearful. The DON stated in an interview that the expectation is to keep residents safe, that abuse can perpetuate and a resident can be hurt more, and that the goal is to have no abuse in the facility. The facility’s Resident Rights policy, revised February 2021, states that federal and state laws guarantee residents the right to be free from abuse, but this right was not upheld when Resident 1 hit Resident 4.
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