Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when one resident, with a known history of aggressive behaviors and alcohol dependence, physically assaulted another resident. The aggressor had a behavioral care plan in place instructing staff to remove other residents or the aggressor from the area if aggressive or verbally inappropriate behaviors occurred. On the day of the incident, the aggressor had been drinking and engaged in a verbal altercation with another resident near the smoking area, which escalated to the aggressor punching the other resident in the face. Staff and clinical notes confirmed that the aggressor had been drinking and that the altercation resulted in a physical assault, though no injuries were noted. The resident who was assaulted had a behavioral care plan addressing high anxiety due to a history of homelessness and medical conditions, with staff directed to provide mental health support. Despite these care plans, staff did not prevent the altercation, and the resident was struck in the face after requesting the aggressor to pick up cigarette butts. Multiple staff interviews confirmed the sequence of events, the aggressor's history of aggressive behavior, and the failure to prevent the physical abuse.