Failure to Train Staff on Recognition and Reporting of Resident-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to ensure all staff received adequate training on the recognition, prevention, and reporting of all forms of abuse, including resident-to-resident abuse, as required by Federal regulations. Surveyors reviewed an interdisciplinary note for one resident dated 2/7/2026, which documented that this resident was punched in the face by another resident, resulting in a 1.2 cm laceration to the right upper eyebrow that required medical attention. The note further documented that the resident who did the punching told staff, “I punched him early in the morning because he tried to have sex with me,” indicating an alleged attempted sexual contact and a physical assault between residents. During interviews, multiple staff members demonstrated that they did not recognize resident-to-resident physical or sexual incidents as abuse. One RN stated he received annual abuse training that covered only staff-to-resident abuse, reporting, and prevention. Another RN described finding dried blood above a resident’s right eyebrow, being told by that resident that another resident had punched him while he was sleeping, and then being told by the alleged aggressor that he hit the resident because the resident wanted to have sex with him. This RN characterized the incident as a physical altercation rather than abuse and did not consider the allegation of attempted sexual contact to be sexual assault or abuse, despite confirming he had received annual abuse training. Additional interviews with the Registered Nurse Shift Lead, the Program Director, and the Nursing Coordinator showed a consistent belief that only staff-to-resident physical or sexual assault constituted abuse and that residents could not be perpetrators of abuse. Review of the facility’s abuse training materials and policies showed that the definitions of physical, psychological, verbal, and sexual abuse were limited to actions by “someone other than another patient,” and sexual abuse was defined in terms of employee conduct or employee allowance of sexual contact between patients. These policy definitions and training content excluded resident-to-resident abuse, contributing directly to staff’s inability to recognize and report the resident-to-resident physical and alleged sexual assault as abuse for two sampled residents.
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