Failure to protect a resident from sexual abuse by another resident. A cognitively intact resident with significant ADL needs and wheelchair use was sharing a semi-private room with another resident who had a BIMS score indicating intact cognition and no documented behaviors toward others. A staff member responding to a call light observed the roommate touching the resident’s genital area and inside his brief under a blanket; the resident said he did not want to be touched, and the facility’s investigation substantiated resident-to-resident abuse.
Failure to Protect Residents from Resident-to-Resident Physical Abuse: Two cognitively intact residents argued over TV volume and a remote, and one resident admitted to scratching the other on the arm. The injured resident had multiple forearm abrasions, and staff interviews confirmed the altercation involved yelling, the remote, and the scratch, with no staff witness to the physical fight.
Failure to Protect Two Residents from Resident-to-Resident Abuse: Two residents with intact cognition and histories including depression and other medical conditions became involved in a verbal dispute that escalated into a physical fight in a hallway near the smoking courtyard. Staff heard yelling and intervened, but both residents swung at each other, and one resident struck the other in the face. Interviews and the investigation confirmed the altercation, with staff describing an ongoing pattern of the two residents instigating each other.
Failure to Protect Resident from Peer-to-Peer Abuse: Two residents were involved in an altercation after one disoriented resident entered another resident’s room and yelling was heard. Staff found bruising and abrasions on the resident who entered the room, and both residents reported that the other had struck first. The incident was investigated as an injury of unknown origin and a significant event, with the facility policy defining physical harm from another resident as abuse.
Failure to Protect Residents from Resident-to-Resident Abuse: Two residents were involved in a verbal altercation that escalated to alleged physical aggression, with one resident reporting being punched in the chest and subjected to racial slurs. Staff observed the conflict, and a CNA stated the other resident initiated the argument and used a racial epithet. The involved resident had a hx of behavioral issues, including agitation, refusal of care, and medication-seeking behavior, while the other resident had diagnoses including paraplegia, schizoaffective d/o, and major depressive d/o.
Failure to Protect Residents From Resident-to-Resident Physical Abuse: Two residents were involved in an alleged physical altercation in a TV room area. One resident had severe dementia and behaviors including fear of unfamiliar men, while the other had severe dementia with psychotic disturbance and behavioral symptoms. An LPN documented that the second resident swatted and appeared to punch the first resident, and that he nodded yes when asked if he meant to hurt her. Staff later disagreed about whether contact occurred after reviewing camera footage, and the DON stated a full investigation and reporting were not required if contact could not be confirmed.
Failure to Protect Residents from Resident-to-Resident Physical Abuse: Two separate resident-to-resident altercations were documented, including one involving a confused resident with severe cognitive impairment who struck a roommate over a walker and another in which a resident with dementia hit another resident with his fists after striking him with a power wheelchair. Staff interviews and records confirmed the physical confrontations, and the DON acknowledged that one resident hitting another resident would be considered physical abuse.
Multiple residents with dementia and behavioral health diagnoses were involved in resident-to-resident abuse incidents that included grabbing a face, striking a resident in the face, hitting a calf with a motorized wheelchair, a chokehold, and holding a resident by the throat and slamming him against a wall. Nursing notes, staff interviews, and facility investigations documented that several residents had known aggression, wandering, agitation, and poor impulse control, yet physical altercations still occurred between residents.
A resident with dementia and behavioral issues was involved in a physical altercation with another resident who had PTSD, bipolar disorder, and a history of aggression. During an activity, the second resident became verbally and physically aggressive, threw items, and struck the first resident with a prosthetic arm/hand; staff heard yelling, rushed in to assist, and police were called. The first resident reported being hit and having minor pain, while the facility’s investigation did not verify the abuse allegation despite staff and resident statements describing the assault.
Two residents with known behavioral issues and cognitive/neurologic conditions were involved in a patio altercation where one resident struck another on the head after a verbal interaction and dispute over a book. Care plans for both residents already identified behavioral disturbances, including verbal and physical aggression, and outlined interventions such as providing a calm environment, diverting attention, and intervening to protect others. Despite these plans and prior documented episodes of verbal aggression and a previous physical altercation involving one of the residents, staff‑witness accounts and later review of video footage confirmed that one resident approached and hit another on the head, causing the victim to report pain and fear, demonstrating a failure to protect residents from physical abuse.
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