Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by two incidents involving a resident with a history of aggression and cognitive impairment. On the morning of 4/16/2025, a resident with diagnoses including paranoid schizophrenia, dementia with anxiety, and major depressive disorder, who was known to be short-tempered and had a documented history of physical and verbal aggression, struck her roommate on the right side of the face and head with a closed fist. The attack was unprovoked, and the victim reported pain rated 6 out of 10, though no physical injury was sustained. The aggressor then left the room and struck another cognitively intact resident at the nurses' station, also with a closed fist, causing pain rated 7 out of 10 but no visible injury. Both victims reported the incidents to staff, and the events were confirmed through interviews and record review. The aggressive resident's care plan had previously documented her tendency to become physically and verbally aggressive due to medication noncompliance, poor coping skills, and mental illness. Prior incidents of aggression toward peers were also noted in her records. Staff interviews confirmed that the incidents were reported to facility administration and that the facility's abuse policy defines abuse as any physical or mental injury inflicted upon a resident, including deliberate actions by cognitively impaired individuals. The facility's failure to prevent these incidents resulted in residents experiencing pain and emotional distress.