Failure to Prevent Resident‑to‑Resident Physical Abuse Resulting in Injuries
Penalty
Summary
The facility failed to protect residents from abuse when two separate resident‑to‑resident altercations occurred, resulting in injuries. In the first incident, a resident with moderate cognitive impairment (BIMS score 10/15) reported that another resident, also with moderate cognitive impairment (BIMS score 9/15), became angry, yelled, and pushed him from his wheelchair to the floor. A nurse later documented that both residents had been holding chairs and positioned defensively in an escalating altercation, and that attempts to de‑escalate were unsuccessful before the aggressor pushed the other resident, causing him to fall forward out of his wheelchair. The injured resident sustained lacerations to the left shin and right knee. The facility’s abuse and residents’ rights policy stated that residents are guaranteed rights to a dignified existence and to be treated with respect, kindness, and dignity. In the second incident, the facility did not prevent an assault by one resident on his roommate, who had severe cognitive impairment (BIMS score 4/15). The aggressor, who had intact cognition (BIMS score 14/15) and a known history of punching others that necessitated a 1:1 sitter, punched his roommate in the face after mistakenly believing the roommate was wearing his shirt. A CNA assigned as a 1:1 sitter stated she did not expect the resident to charge and punch the roommate while he was being escorted, and another CNA described the aggressor abruptly getting up, charging, and punching the roommate in the face while she was at the bedside setting up a meal tray. The injured resident sustained swelling below the right eye, for which pain medication and an ice pack were provided. These events occurred despite the facility’s written policy on abuse reporting, investigation, and residents’ rights to be treated with respect and dignity.
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