Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two vulnerable residents from resident-to-resident physical abuse. In the first incident, one resident in a wheelchair attempted to move past another resident in a hallway, making physical contact. The standing resident, who had a history of bipolar II disorder, anxiety, PTSD, and prior verbal/physical aggression, responded by hitting the resident in the wheelchair on the head. Both residents were assessed as having no cognitive impairment, and both had documented histories of behavioral issues and high risk for abuse/neglect. No staff were present to witness or intervene during the altercation, and there was no documented aggression screening for the resident who initiated the physical contact. Staff were supposed to monitor the area but were not present at the time of the incident. In the second incident, a resident with severe cognitive impairment reached for another resident's drink at the dining table. The other resident, who had no cognitive impairment but a history of major depressive disorder and prior peer conflict, reacted by swatting the first resident's hand. This incident was witnessed by the Assistant Director of Nursing, who observed that no other staff were nearby, as aides were occupied picking up trays in the vicinity. The resident who initiated the physical contact had no documented aggression screening in their medical record, despite a history of behavioral issues. Both incidents involved residents with documented behavioral and psychiatric histories, and in both cases, staff were either not present or not actively monitoring the areas where the altercations occurred. The lack of staff supervision and absence of aggression screening for residents with known behavioral risks contributed to the facility's failure to prevent resident-to-resident physical abuse.