Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement effective interventions to prevent abuse among residents, specifically involving three residents with a history of aggressive or abusive behavior. On one occasion, an altercation occurred in the dining room where one resident blocked and kicked another, resulting in pain and distress. Staff and family interviews confirmed that the aggressive resident had a pattern of bothering and physically assaulting others. Documentation showed that the resident who was assaulted was cognitively intact, while the aggressor was severely cognitively impaired and had a documented history of aggression toward both residents and staff. Another incident involved the same aggressive resident pushing a severely cognitively impaired resident to the ground, causing a skin tear. Staff observed the aggressive behavior and noted that the resident was difficult to manage, often cursing and being physically aggressive. Despite the care plan identifying the risk of aggression and the need for interventions to protect others, records indicated that interventions were largely unsuccessful, and more effective measures such as moving the resident or providing 1:1 observation were not implemented prior to the incidents. The facility's policy required the administrator to determine protective actions upon receiving abuse allegations, but the documented actions were insufficient to prevent repeated altercations.