Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect three residents from resident-to-resident physical abuse, as required by its own abuse prevention policy. The incidents involved a resident with moderate dementia and behavioral disturbances who exhibited escalating agitation and aggression. This resident entered another resident's room without permission, despite being redirected multiple times earlier for disruptive and intrusive behaviors in the dining room. The resident attempted to take snacks from another resident, who verbally asked him to leave. When the request was ignored, the intruding resident kicked the other resident in the shin. Following this, a third resident, who had severe cognitive impairment and was a roommate of the aggressive resident, intervened after hearing calls for help. This resident physically struck the aggressive resident in the back and attempted to remove his wheelchair from the doorway. In response, the aggressive resident turned and kicked the intervening resident on the leg. These events were confirmed by video surveillance, resident interviews, and staff accounts, all of which documented the sequence of physical altercations among the residents. The facility's staff had observed the aggressive resident's escalating behaviors earlier in the dining room, including attempts to take other residents' belongings and food, and had redirected him to his room. However, after being left unsupervised, the resident exited his room and initiated the altercation. The staff did not provide adequate supervision or intervention to prevent the resident from entering another resident's room and engaging in physical abuse. The facility's failure to ensure effective supervision and protection resulted in multiple instances of resident-to-resident physical abuse.