Failure to Prevent Resident-to-Resident Physical Abuse in Dining Area
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident (R1) from physical abuse by another resident (R2). On the evening of 3/6/26, R2 was observed by staff to be singing loudly, running back and forth in the dining area, and was described as non-redirectable, with residents complaining about the noise. R1, who has diagnoses of schizophrenia, major depressive disorder (recurrent, moderate), and generalized anxiety disorder and was assessed as cognitively intact, was in the dining room with other residents attempting to talk and watch a movie. R2 placed his phone on the table where R1 was sitting; R1 moved the phone to another table and told R2 he did not want the phone on his table, and also called R2 a curse word. R2 then grabbed R1 from behind, pushed him to the floor, and stood over him until staff separated them. R1 initially reported feeling okay and not hurt, with staff documentation noting no injury other than slight redness to an elbow at the time of assessment. During the investigation, R1 later reported bruising and pain to his right elbow and lower back, stating that the elbow injury occurred when he landed on the floor. Staff accounts, including the RN assigned to both residents and the DON, confirmed that R2 had been running around, talking or singing loudly, and was not redirectable prior to the incident, and that R2 physically grabbed and pushed R1 to the ground after R1 moved his phone. R2’s face sheet shows a diagnosis of schizoaffective disorder, bipolar type, and his MDS indicated he was cognitively intact, with no prior history of aggression at the facility. The facility’s Abuse Prevention Policy states that physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that the facility is committed to protecting residents from abuse and doing all that is within its control to prevent occurrences of abuse. The final incident investigation concluded that physical abuse was founded, determining that R2’s act of grabbing and pushing R1 to the ground constituted physical abuse. Both the Administrator and the DON acknowledged in interviews that the event was physical abuse and that it is the facility’s job to prevent abuse, indicating that the facility did not keep R1 free from abuse as required by its policy and regulatory standards.
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