Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a cognitively impaired resident from physical and emotional abuse by another resident. Both residents involved had severe cognitive impairment and histories of behavioral issues, including dementia and aggressive or agitated behaviors. The incident occurred when one resident physically assaulted the other, resulting in scratches, a bite mark, and emotional distress. Staff found both residents on the floor, with one resident biting the other's fingers and subsequently slapping him on the face. The assaulted resident was observed to be crying, scared, and visibly upset, with multiple minor injuries documented. Prior to the incident, the care plans for both residents identified significant risk factors. One resident had a documented history of childhood abuse, severe cognitive impairment, and a pattern of wandering into peers' rooms, which was known to startle or upset others. The other resident had a history of aggressive behavior, agitation, and resistance to care, as well as recent medication orders for agitation and anxiety. Despite these known risks, the facility did not implement effective interventions to prevent resident-to-resident altercations or address the potential for abuse between these two individuals. Staff interviews revealed that the two residents had a history of negative interactions, with one resident frequently being mean and attempting to exclude the other from their shared room. On the day of the incident, staff were not present in the room at the time of the altercation and were alerted by another resident. Upon intervention, staff observed the aggressor laughing and making statements that the victim "deserved it." The facility's abuse policy affirms the right of residents to be free from abuse and requires the prevention of mistreatment, but the lack of adequate interventions and supervision led to the occurrence of abuse and emotional harm.