Failure to Prevent and Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to prevent and protect residents from physical abuse, as evidenced by two separate physical altercations between two residents with intact cognition and histories of mental health disorders. Both residents had documented histories of aggressive and inappropriate behavior, including prior incidents of agitation and aggression. On the day of the incident, the first altercation occurred in the lobby, where one resident verbally provoked the other, leading to a physical fight in which punches were exchanged, resulting in a bloody nose for one resident. Multiple staff members, including an escort, activity aide, and maintenance director, were present and intervened to separate the residents. Despite the initial altercation, both residents were kept in proximity to each other on the same floor. Approximately an hour later, a second physical fight occurred in the same area, with both residents again exchanging blows, resulting in one being pinned to the ground and complaining of back pain. Staff had difficulty separating the residents during the second incident, and police and paramedics were called to the facility. Both residents were subsequently transferred to the hospital for evaluation and treatment. Interviews with staff revealed that there was a lack of specific training and procedures on how to handle abuse situations, and several staff members, including the maintenance director and DON, acknowledged that the second fight could have been prevented if the residents had been separated after the first incident. The facility's policies required the prevention of abuse, but staff actions did not prevent repeated physical altercations between the residents, resulting in physical harm.