Failure to Prevent Resident-to-Resident Physical Abuse Involving Cognitively Impaired Residents
Penalty
Summary
The facility failed to protect three residents from physical abuse by another resident. One resident (R1), admitted with dementia and anxiety disorder and assessed with a BIMS score of 3/15 indicating severely impaired cognition, physically assaulted two other cognitively impaired residents. Another resident (R2), admitted with Alzheimer's disease and dementia and assessed with a BIMS score of 0/15, was observed during a facility-reported incident on 12/4/25 at approximately 5:30 PM in an argument with R1 at the end of the hallway. Staff, including an LPN, witnessed R1 holding and aggressively squeezing R2's right wrist. R2 was noted to have bruising on the right hand and wrist, and R1 later was documented to have a reddish-purple bruise and a skin tear on the top of the left hand. Both residents were unable to provide an account of the incident, and R1 believed R2 was trespassing in R1's room. In a separate facility-reported incident on 12/9/25, R1 targeted another resident, R4, who was also admitted with dementia and anxiety disorder and had a BIMS score of 0/15, indicating severely impaired cognition. Staff observed R1 stick a leg out in front of R4's wheelchair as if to trip R4, then become aggressive, grab R4's right hand/wrist, and refuse to let go. R4 called out, stating that R1 was hurting them, and was later documented to have two bruises on the right hand. An RN progress note and staff interviews confirmed that R1 attempted to trip R4 and grabbed R4's right hand, causing pain and visible bruising. These incidents demonstrate that the facility did not prevent resident-to-resident physical abuse involving vulnerable, cognitively impaired residents.
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