Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in multiple incidents of resident-to-resident altercations. In one incident, a resident with intact cognition and a history of anger issues physically struck another resident during a dispute over seating on the smoking patio. The altercation was preceded by verbal exchanges and escalated to physical contact, with staff intervening after the event. The involved residents had no prior history of conflict, but both had behavioral concerns documented in their care plans. Another incident involved two roommates with a history of verbal arguments. One resident, who had previously threatened the other and had a diagnosis of paranoid schizophrenia, physically assaulted her roommate, causing visible injury. Staff were aware of ongoing verbal conflicts between the two but did not separate them prior to the physical altercation, citing lack of available rooms and resident refusals to move. The altercation resulted in one resident being sent to the hospital for psychiatric evaluation. A third incident occurred in the dining room, where a verbal argument between two residents escalated to physical violence. One resident, who had a history of mood distress and anger, was punched and pulled to the ground by another resident following an exchange of insults. Staff responded promptly to separate the residents, and both later apologized. The residents involved had no prior history of conflict, and the aggressor was a new admission who discharged herself against medical advice the same day. In all cases, the facility's policies on abuse prevention and resident rights were not effectively implemented to prevent these incidents.