Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents from abuse during an incident where one resident slapped another on the buttocks, and the second resident responded by hitting the first in the face. The first resident, a male with dementia, cognitive communication deficit, and a history of inappropriate sexual behavior, was known to have a habit of touching or grabbing people as they walked by. His care plan indicated a need for a structured environment and noted his behavioral issues, including inappropriate sexual behavior and agitation. On the day of the incident, he slapped another male resident on the buttocks, which was documented in progress notes and confirmed by staff interviews. The second resident involved had diagnoses including bipolar disorder, schizoaffective disorder, and schizophrenia, with a history of behavioral problems such as indecent exposure, public touching, and physical aggression when triggered by inappropriate touch. His care plan also indicated a need for a structured environment and noted poor impulse control. After being slapped on the buttocks, he immediately turned and punched the first resident in the face, causing a superficial scratch and redness. This reaction was consistent with his care plan, which stated he could be triggered for physical aggression when touched in a way he perceived as inappropriate. Staff interviews revealed that both residents had known behavioral issues, and staff were aware of the potential for such incidents. Multiple staff members described the first resident as "grabby" but not aggressive, and the second resident as someone who did not like to be touched due to past trauma. The facility's policy defined abuse as any non-consensual sexual contact or willful infliction of injury, and staff acknowledged that the incident could have caused physical or psychological harm. Despite this, the facility failed to prevent the incident, resulting in both residents being exposed to abuse.