Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in multiple incidents involving physical altercations between residents. In one incident, two female residents, both with mental health diagnoses and intact cognitive function as indicated by their BIMS scores, engaged in a physical altercation in an elevator. One resident reported being pushed and scratched by the other, leading to both residents exchanging blows and sustaining minor scratches. Staff on the unit heard raised voices and intervened, but were unable to separate the residents before the altercation escalated. Both residents were assessed and treated for their injuries, and the incident was substantiated as abuse by the facility. In a separate incident, another female resident with a history of schizoaffective disorder and chronic kidney disease was struck in the head by a peer in the dining room without provocation. The aggressor, who has severe mental illness and unscoreable BIMS, became agitated and refused to answer questions when staff attempted to interview her. Staff intervened immediately to separate the residents, and both were assessed with no injuries reported. The incident was also substantiated as abuse. In both cases, the facility's failure to prevent resident-to-resident physical abuse resulted in physical contact and minor injuries. The incidents involved residents with significant behavioral and mental health diagnoses, and staff intervention occurred only after the altercations had already begun. The facility's abuse prevention policy states that residents have the right to be free from abuse, neglect, exploitation, misappropriation of property, or mistreatment, but these incidents demonstrate a failure to uphold that standard.