Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident, resulting in significant injuries. On the morning of 3/31/2025, a resident with severe cognitive impairment and a history of dementia and bipolar disorder physically assaulted two other residents. The first incident occurred when one resident, who was sitting in a wheelchair and swinging a doll, had the doll make contact with the aggressor. In response, the aggressor struck the resident multiple times in the face with a closed fist, causing facial contusions, swelling, discoloration, bleeding from the mouth, and a closed head injury. The injured resident reported moderate pain and was subsequently transferred to an acute care hospital for further evaluation and treatment. Shortly after the first incident, the same aggressor approached another resident standing near the nurse's station. The aggressor pulled the resident's shirt and necklace from behind, breaking the necklace, and held the resident around the neck, resulting in redness on the left side of the neck. Both victims had severe cognitive impairment and diagnoses including dementia and other mental health conditions, making them particularly vulnerable to abuse. Staff interviews and documentation confirmed that the aggressor's actions were willful and met the facility's definition of abuse. The facility's policies required the provision of a safe environment and the prevention of abuse, but these were not effectively implemented, as evidenced by the occurrence of resident-to-resident altercations resulting in physical harm.