Failure to Protect Cognitively Impaired Residents From Peer-to-Peer Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect cognitively impaired residents from physical abuse by another resident with known aggressive behaviors. One resident (R1), who is cognitively impaired with poor vision and a history of wandering into other residents’ rooms and beds, was documented in a behavior note dated 2/27/2025 as having an alleged physical altercation with another resident (R2), resulting in bruises and a skin tear to the right forearm measuring 5 cm by 3 cm. An LPN (V6) reported witnessing this physical altercation on the evening of 2/27/2026 and confirmed that R1 sustained a skin tear from the incident. R1’s family member (V7) stated they were notified of this altercation and the resulting skin tear. During observation on 3/21/2026, R1 was seen wandering independently around the dining room and had a healed wound on the right forearm, and staff interviews confirmed R1 is usually verbally, but not physically, aggressive. The same aggressive resident (R2), who has severely impaired cognition per the MDS and is care planned for potential physical aggression related to anger, dementia, depression, history of harm to others, and poor impulse control, was repeatedly described by staff as verbally and physically aggressive, particularly toward staff and sometimes toward other residents. A CNA (V4) and an activity aide (V5) reported that R2 can become aggressive when frustrated or overstimulated, with V5 noting that R2 sometimes attempts to get physical with other residents and that staff usually remove R2 before this occurs. R2’s nurse’s notes and behavior notes dated 2/25/2026 and 2/27/2026 document alleged physical altercations with other residents. Another cognitively impaired resident (R5), who has care plans for problematic behaviors including verbal/physical aggression and hoarding/rummaging related to dementia and mood disorders, was also documented in a nurse’s note dated 2/25/2026 as having an alleged altercation with R2. Despite the facility’s written Abuse Prevention and Reporting Policy affirming residents’ right to be free from abuse and prohibiting abuse, these documented altercations show that residents R1 and R5 were not protected from physical abuse by R2.
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