Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents from resident-to-resident abuse, as evidenced by an incident in which the two roommates engaged in a physical and verbal altercation. Both residents had mild cognitive deficits, with one having a history of physical aggression towards staff and the other having a care plan addressing her relationship with a male companion. Despite these behavioral histories, the residents were placed together as roommates, which ultimately led to conflict. On the day of the incident, one resident was exiting the shared bathroom as the other attempted to enter, resulting in an exchange of words and a physical struggle where they grabbed each other's arms and hands. The altercation was not immediately reported to staff; instead, the residents resolved the issue themselves and only disclosed the event two days later. Interviews with another resident and review of incident reports indicated a pattern of previous verbal and physical altercations involving one of the residents. The facility's documentation revealed that no skin assessments were performed for either resident following the incident, and the care plans did not address the risk of resident-to-resident altercations. The facility's policy guarantees residents the right to be free from abuse and neglect, but the failure to prevent and promptly address the altercation between the two residents constituted a deficiency in protecting residents from abuse.