Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent one resident from physically abusing another resident, resulting in physical harm. Resident #2, who was cognitively intact and had a history of behavioral issues including outbursts of anger and exposing himself, was involved in an altercation with Resident #4 on the facility patio. During this incident, Resident #2 knocked out Resident #4's tooth, while Resident #4 struck Resident #2 with a stick. The altercation was documented in progress notes, and both the police and Adult Protective Services were notified immediately after the event. Resident #4, also cognitively intact and with a history of behavioral problems such as making false accusations and interfering with facility protocols, lost newly cemented dental bridges as a result of the altercation. Interviews confirmed that Resident #4 had been involved in previous altercations at the facility. The facility's policies on abuse and resident rights, which prohibit physical abuse and guarantee freedom from abuse and neglect, were reviewed as part of the investigation. The administrator confirmed the loss of the tooth and noted that the resident refused treatment.