Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by other residents, as evidenced by an altercation between two residents with known behavioral issues. One resident, with a history of major depressive disorder, psychotic disorder, dementia, bipolar disorder, PTSD, paranoid schizophrenia, and anxiety disorder, was identified as having moderate cognitive impairment and a care plan noting behavior problems related to physical aggression. The other resident, diagnosed with muscle weakness and major depressive disorder, was cognitively intact. Both residents were documented as being both givers and receivers of physical aggression in their care plans. On the day of the incident, a verbal altercation escalated when one resident was waiting for the other to retrieve items from a breakfast cart. After an exchange of words, one resident struck the other, who then followed him to his room and threw water on him, leading to a physical fight. The incident resulted in a minor injury, specifically a skin tear on one resident's hand. Staff interviews confirmed that the altercation was provoked by verbal exchanges and that both residents had a history of aggressive interactions. The facility's policy required staff to monitor behaviors that could provoke reactions and to review resident-to-resident abuse as potential abuse situations. Despite being aware of one resident's history of altercations at another facility and the behavioral risks identified in both residents' care plans, the facility did not implement sufficient measures to prevent the altercation. The failure to adequately monitor and intervene placed residents at continued risk of harm.