Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving two residents out of a sample of ten. In one incident, a resident with moderate cognitive impairment and a history of behavioral disturbances made inappropriate physical contact with another cognitively intact resident while waiting in a hallway. The incident was not witnessed by staff, and the affected resident reported that the inappropriate contact continued until staff arrived to open the door. The resident who committed the act had previous allegations of similar behavior involving other residents, some of which were witnessed by staff. In a separate incident, a resident with severe cognitive impairment and a history of wandering entered another resident's room and attempted to take items from his table. This led to a physical altercation, during which the resident with severe dementia sustained a small scratch above her eyebrow. The altercation was witnessed by a roommate, who sought help from staff. The resident who initiated the physical contact was also severely cognitively impaired. The wandering resident had a documented history of similar incidents involving entering other residents' rooms and making physical contact. The facility's abuse prevention policy requires staff to identify residents at risk for abuse or with behaviors that may lead to conflict, and to address these risks through care planning and regular monitoring. Despite this policy, the facility did not prevent repeated incidents of resident-to-resident abuse, including both inappropriate sexual contact and physical altercations, involving residents with known behavioral risks and histories of similar incidents.