Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. One resident, who was cognitively intact and had no behavioral symptoms, was using her bathroom when another resident, who had a history of schizoaffective disorder, severe cognitive impairment, and aggressive behaviors, entered the bathroom uninvited. The intruding resident attempted to take a trash can from the bathroom, and when the first resident intervened, he punched her in the face, leaving a red mark and causing pain. The incident occurred while the resident was sitting on the toilet with her pants down, which left her feeling mad, embarrassed, and violated. Prior to the incident, the resident who committed the abuse had a documented history of psychiatric issues, including disorganized thought processes, aggressive behavior, paranoid delusions, and poor impulse control. Staff interviews and care plan reviews indicated that this resident was known to become easily agitated, had previously threatened staff, and had a pattern of entering other residents' rooms without permission. Despite these known risks, the resident was ambulatory and allowed to walk freely throughout the facility, including unsupervised access to hallways and other residents' rooms. Observations and staff interviews revealed that there was a lack of staff presence in the hallway near the incident location at the time of the event. The facility's policy on abuse prevention and reporting defined resident-to-resident abuse as aggressive or inappropriate behavior, including hitting and threatening gestures. The failure to provide adequate supervision and monitoring allowed the aggressive resident to access another resident's private space and commit physical abuse, resulting in physical and emotional harm.