Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from verbal and physical abuse by other residents, as evidenced by multiple altercations involving three residents with severe cognitive impairments and histories of behavioral issues. In one incident, a resident with dementia and violent behavior attempted to touch another resident's watch, resulting in the second resident, who also has dementia and a history of physical aggression, grabbing the first resident's wrist and causing a skin tear. Both residents were identified as being at moderate risk for abuse, and their care plans documented behavioral problems and tendencies toward aggression. In a separate incident, another resident with dementia and a history of aggressive behaviors attempted to move a wheelchair occupied by a resident with dementia and agitation. This led to a physical altercation where the resident in the wheelchair swung her arms, and the other resident responded by striking her in the face. The altercation escalated further when the resident who was struck used a racial slur. These events demonstrate that the facility did not adequately prevent or intervene in resident-to-resident abuse, despite documented risks and behavioral histories.