Resident-to-Resident Abuse Involving Pillow Over Face
Penalty
Summary
The facility failed to protect a resident from abuse when one cognitively impaired resident placed a pillow over the face of another cognitively impaired resident. The resident identified as the victim, R6, had been admitted with diagnoses including coronary artery disease, hypertension, benign prostatic hyperplasia, hyponatremia, and hyperlipidemia, and had a Brief Interview for Mental Status (BIMS) score of three, indicating a severe cognitive deficit. The resident identified as the aggressor, R5, had been admitted with non-traumatic brain dysfunction and dementia and also had a BIMS score of three, indicating a severe cognitive deficit. During the incident on 1/6/2026, R5 placed a pillow over R6’s face. The facility’s own investigation documented that the act of placing the pillow over R6’s face occurred and was substantiated as resident-to-resident abuse. The facility’s policy titled “Abuse, Neglect, and Exploitation” states that its intent is to actively preserve each individual’s right to be free from mistreatment, neglect, abuse, or misappropriation of resident property. Interviews with the DON and the Administrator/Abuse Coordinator confirmed that the incident between R5 and R6 met the definition of abuse under facility policy and that resident-to-resident abuse was confirmed. This sequence of events demonstrates that the facility did not ensure that R6 was free from abuse as required by its policy and regulatory standards.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.