Failure to prevent repeated resident-to-resident physical abuse occurred when a resident with Alzheimer’s disease, dementia with agitation, depression, severe psychotic disorder with delusions, and wandering was involved in multiple altercations with peers. The resident’s care plan documented agitation, physical aggression, verbal aggression, wandering into peers’ rooms, and taking items, and progress notes showed incidents of grabbing, kicking, flicking, hitting, choking, and punching other residents, as well as being struck by peers during these events. Admin staff said behaviors were discussed daily, but the facility did not effectively manage the resident’s behaviors, resulting in repeated abuse episodes.
Failure to protect residents from abuse occurred when one resident, who returned from an outing intoxicated, kissed another resident in the hallway. The other resident had dementia and severely impaired cognition. A CNA observed the incident, both residents were redirected, and the on-call nurse and DON were notified. An admin staff member confirmed the sexual incident.
Failure to Prevent Resident-to-Resident Abuse: Surveyors found repeated resident-to-resident abuse involving hitting, slapping, scratching, and one report of a resident grabbing another resident by the neck. A resident with dementia and impaired decision-making was involved in multiple altercations with several other residents, while care plans did not address wandering, rummaging, or aggressive behaviors. Records also showed other residents with dementia, Alzheimer’s disease, PTSD, and other conditions were involved, and staff confirmed the incidents and the lack of individualized behavior interventions.
Failure to protect residents from inappropriate sexual contact occurred when a resident with dementia and a history of inappropriate touching placed a hand down another resident's shirt. The other resident also had dementia and severely impaired cognition. Staff reported the incident, separated the residents, and noted the first resident frequently touched staff and residents and required redirection.
Resident-to-resident abuse occurred when a resident with dementia and a BIMS score of 9 slapped another resident during a verbal exchange over eyeglasses placed on a therapy cat. The other resident had dementia, anxiety, and impaired cognition with confusion and nonsensical responses during interview. Camera footage confirmed the open-hand contact, and both residents later could not recall the incident.
A facility failed to protect two residents from physical abuse by each other after a roommate conflict over food escalated into an unwitnessed altercation involving hair pulling, hitting, and biting. One resident with intact cognition and another with dementia and impaired cognition became physically aggressive, and the incident involved bodily fluids that required bloodborne pathogen testing.
A resident with dementia, restlessness, agitation, and a documented history of entering others’ rooms, rummaging, and exhibiting verbal and physical behaviors was involved in multiple abusive encounters with other residents. In separate incidents, this resident hit another resident in a TV lounge after handling that resident’s bag, punched a resident on the chin/cheek while following behind with a walker, grabbed another resident’s arm near the TV leading to mutual hitting and a fall onto a recliner occupied by a third resident, kicked a resident while being escorted to dinner, and lifted a resident’s chair cushion while searching for a wallet, leading to a profane verbal exchange. Several of the involved residents had impaired cognition, while others had intact cognition but histories of mood and behavioral issues. Staff interviews showed limited description of immediate protective actions when witnessing resident-to-resident aggression, and an administrator noted that the aggressive resident had not been evaluated by psychiatry for an extended period. The facility failed to prevent repeated verbal and physical abuse among residents, resulting in retaliatory abuse toward the aggressive resident.
The facility failed to prevent resident-to-resident physical abuse when a cognitively impaired resident with dementia-related behavioral issues, already care planned for aggressive mood fluctuations and a history of physical contact, grabbed and forcefully squeezed another resident’s arm in a hallway and, in a separate episode, yelled and struck another cognitively impaired resident in the face multiple times while they were seated together. In both incidents, the affected residents, who had dementia and other psychiatric diagnoses, reported or were documented as having been physically assaulted, though no injuries were ultimately noted, demonstrating that residents were not kept free from abuse by another resident as required by facility policy.
Failure to protect a resident from physical abuse resulted in a bruise to the resident's arm after another resident yanked the resident's wrist and slapped the resident's face. The injured resident had dementia with psychotic disturbance, anxiety, depression, restlessness, and agitation, and was unable to explain what happened. The other resident had dementia with agitation, depression, irritability/anger, and psychotic disorder with hallucinations; the care plan noted a tendency for physical and verbal behaviors but did not address aggression toward other residents, and staff confirmed the incident was not thoroughly reported or investigated.
A resident with Alzheimer's disease, anxiety, moderate cognitive impairment, and a known history of physical and verbal aggression repeatedly exhibited abusive behaviors toward other residents, including shoving, slapping, swinging, and yelling at them, as documented in multiple progress notes and the care plan. Video from a reported incident showed this resident exiting another resident’s room, approaching a male resident in the hallway, and pushing him to the floor before quickly leaving, consistent with the facility’s policy definition of resident-to-resident physical abuse. The medical record did not contain documentation of this specific pushing incident, despite the facility’s awareness of the resident’s ongoing aggressive behaviors and stated expectations that staff monitor, intervene, and report such events.
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