Failure to Protect Residents from Physical Abuse by Staff and Peers
Penalty
Summary
The facility failed to protect residents from physical abuse in two separate incidents involving both staff-to-resident and resident-to-resident altercations. In the first incident, a resident with schizoaffective and bipolar disorder, who was cognitively intact and independent in activities of daily living, was involved in a physical fight with a primary counselor inside the resident's assigned room. The resident initially reported a fall but later disclosed the altercation, which was corroborated by the roommate and another staff member. The resident sustained a swollen right palm and an abdominal bruise as a result of the incident. The facility's investigation confirmed that the physical altercation occurred in the presence of another staff member who did not intervene. In the second incident, two residents with intact cognition and independence in daily activities engaged in a physical altercation after a verbal dispute escalated. One resident approached the other in the hallway, and after an exchange of words, initiated physical contact by hitting the other resident, who then retaliated. Staff interviews revealed that although staff were present and heard the argument, they did not intervene until the altercation became physical. Both residents required x-rays following the incident, and one resident reported nasal pain as a result of being struck in the nose. The facility's policies defined physical abuse to include hitting and other forms of corporal punishment, and required protection of residents from such harm. In both cases, staff failed to prevent or promptly intervene in the altercations, resulting in residents being subjected to physical abuse and requiring medical evaluation. The incidents were substantiated by resident and staff interviews, as well as medical records documenting the injuries sustained.