Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect multiple residents from physical abuse during a series of resident-to-resident altercations. One incident involved a resident with severe cognitive impairment and a history of wandering and entering others' personal space, who was pushed to the ground by another resident after following them into their suite. This resulted in the resident sustaining a hematoma above the left eyebrow and an abrasion under the left eye. The care plan for this resident had identified the risk of harm from others due to cognitive deficits, but interventions to prevent such incidents were not effectively implemented at the time of the altercation. Another incident involved a resident with severe cognitive impairment and anxiety who experienced distress when another resident entered their room without permission. The two residents were found on the floor kicking at each other after one entered the other's room, resulting in minor injuries including a skin tear, bruise, and scratch. The care plan for the resident who was protective of personal space included interventions to redirect other residents, but these measures were not sufficient to prevent the altercation. Staff interviews and documentation revealed that the facility was undergoing a transition that increased resident agitation and led to a rise in resident-to-resident incidents. The root cause was identified as insufficient supervision throughout the unit, which contributed to the failure to prevent these altercations. The lack of timely staff intervention allowed the incidents to escalate, resulting in actual harm to at least one resident.