Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving four residents with significant cognitive and psychiatric impairments. In one incident, a resident with severe cognitive impairment and multiple psychiatric diagnoses became upset and engaged in a physical altercation with another resident in the dining room. The altercation escalated, resulting in one resident attempting to retaliate and subsequently sliding out of her wheelchair. Staff intervened, and the resident who initiated the altercation was sent for psychiatric evaluation. No injuries were noted, but the event was confirmed through investigation and resident interviews. In another incident, two residents with histories of dementia, bipolar disorder, and other psychiatric conditions were involved in a physical altercation over a chair in a common area. One resident pushed the other, who then attempted to hit back with a chair. Staff intervened to separate the residents and prevent injury. Both residents had documented histories of behavioral issues and were known to argue frequently. No injuries were reported, but the altercation was witnessed by multiple staff members and confirmed through progress notes and interviews. All residents involved had care plans indicating a risk for abuse and neglect, with documented behavioral challenges such as hallucinations, delusions, impulsive behavior, and aggression toward others. Despite these known risks and behavioral histories, the facility did not prevent the altercations from occurring, resulting in physical contact and the need for staff intervention. The facility's abuse prevention policy affirms the right of residents to be free from abuse by anyone, including other residents, but these incidents demonstrate a failure to uphold that standard.