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.
A resident with dementia, anxiety, and depressive disorder became upset with another resident who frequently called out for help, told her to “shut up,” and slapped her on the right cheek as he passed by. CNAs witnessed the exchange and separated the two residents. The resident who was struck, who had Alzheimer’s disease and anxiety, was later documented with a small, dime-sized bruise under her right eye aligned with her glasses, though she denied pain and did not recall the event. Despite a written abuse and neglect policy prohibiting abuse by anyone, including other residents, the incident showed the facility failed to ensure residents remained free from physical abuse.
The facility failed to prevent resident-to-resident abuse in two separate incidents involving vulnerable residents with dementia and behavioral histories. In one case, a male resident with known inappropriate sexual behaviors was found by a CNA in a female resident’s room, sitting on her bed, kissing her, and touching her breasts under her shirt, despite her later stating she did not like the contact and a provider determining she could not consent due to cognition. In another case, a male resident with psychosis, intermittent explosive disorder, traumatic brain injury, and a history of aggression toward others struck a cognitively impaired female resident on the cheek because her noise bothered him, later stating she deserved it. These events occurred despite care plans and policies that identified the residents’ behavioral risks and prohibited abuse by other residents.
A resident with mild vascular dementia, agitation, and a documented history of socially inappropriate and physically aggressive behaviors punched another cognitively impaired resident with traumatic brain injury and dementia in a common area. Staff heard yelling and then observed the aggressor standing over the injured resident with a raised fist after the punch. The aggressor admitted he intended to cause pain and expressed no remorse. The injured resident reported facial and headache pain, with redness noted on the left side of the face, and was evaluated in the ED before returning with mild residual redness and reduced pain.
The facility failed to protect residents from abuse when multiple resident-to-resident altercations occurred despite an existing Abuse Prevention Plan. In one case, a resident in a wheelchair was kicked and punched in the jaw by a roommate with known agitation and a history of physical altercation. In other cases, a cognitively impaired resident was slapped during an activity and later pushed, kicked, and slapped in her room by other residents with moderate cognitive impairment, after another resident told her to stop singing and to shut up. Although assessments found no significant physical injuries or expressed distress, the involved residents’ care plans contained identical, non-individualized interventions and a vague problem statement about being vulnerable adults, without clear, specific strategies for managing violent or physically aggressive behavior, contributing to repeated incidents of abuse.
Two residents experienced abuse, including yelling, intimidation, and threats by staff, as well as physical altercations between residents. Staff failed to use proper de-escalation techniques, did not maintain resident dignity, and did not report incidents or injuries promptly to supervisory staff, resulting in unaddressed physical and mental distress.
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