Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving two residents with psychiatric diagnoses. One resident, who is cognitively intact and diagnosed with paranoid schizophrenia, was seated next to another resident with moderately impaired cognition, unspecified schizophrenia, and a history of aggressive and abusive behavior. While watching a movie in the dining/day room, the resident with a history of aggression began lightly punching the other resident's arm, escalating to harder punches. The recipient of the punches did not initially report the behavior, as it was consistent with the aggressor's known conduct, but eventually retaliated by grabbing the aggressor's hand and kneeing him in the abdomen. This resulted in the aggressor losing balance and falling to the floor. Multiple staff interviews confirmed that the aggressive resident had a pattern of socially inappropriate and intrusive behavior, including touching others without consent. Staff present at the time witnessed the escalation and responded after the physical altercation had already occurred. Both residents sustained injuries and were sent to the hospital for evaluation. The incident highlights a failure to adequately supervise and intervene to prevent physical abuse between residents, particularly given the known behavioral history of one of the individuals involved.