Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent physical abuse between two residents, both of whom were cognitively intact and had significant psychiatric and physical diagnoses. The incident occurred when one resident was taking a shower and another entered the bathroom, ignoring requests to leave. The situation escalated when the second resident bumped the first resident's shower chair and continued to harass him. The first resident, after drying off and attempting to leave, was confronted again by the second resident, who threw a urinal full of urine at him. In response, the first resident struck the second resident on the back of the head. The altercation continued in the hallway, with further physical aggression and the first resident slipping on urine and falling. Staff became aware of the incident after hearing yelling and observed the residents in a physical altercation. Despite staff attempts to intervene, the situation escalated, with one resident dumping urine on the other and a wheelchair being flipped. Both residents were assessed and found to have no injuries. The facility's abuse prevention policy prohibits any form of abuse, including physical or mental injury inflicted by non-accidental means. The events described demonstrate a failure to prevent resident-to-resident physical abuse as required by facility policy.