Failure to Prevent and Report Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent multiple instances of resident-to-resident physical abuse involving four residents in the memory care unit. Observations included a resident pacing unsupervised, using derogatory language, and physically assaulting another resident by pinching and hitting her, which caused the victim to scream. Despite staff intervention, the aggressor was left unsupervised and immediately engaged in similar behavior with another resident. Review of incident and accident reports over a six-month period revealed repeated altercations, including hitting, slapping, pushing, and grabbing between residents, with several incidents not reported to the State Agency as required. Interviews confirmed that while staff investigated these altercations, the incidents continued to occur. The facility's own policy mandates the prevention of abuse, neglect, and exploitation, yet the documented events show a pattern of resident-to-resident abuse that was not effectively prevented or reported. The residents involved were in the memory care unit, indicating cognitive impairment, and the altercations often resulted in physical harm such as skin tears and distress.