Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from abuse by not preventing resident-to-resident physical altercations. Multiple incidents were documented in which residents with severe cognitive impairments and behavioral disturbances engaged in physical aggression toward each other. These incidents included slapping, hitting, and grabbing, often occurring in common areas such as hallways and dining rooms, as well as in resident rooms. Staff members witnessed these altercations and intervened to separate the residents, but the events still resulted in physical contact and, in some cases, visible injuries such as redness to the face. Several residents involved had diagnoses including Alzheimer's disease, dementia with behavioral disturbances, schizoaffective disorder, and other psychiatric or cognitive conditions. Care plans for these residents noted behavioral symptoms such as physical aggression, wandering, and poor impulse control. Despite these documented risks, altercations occurred repeatedly, with staff sometimes present in the area but unable to prevent the incidents. In some cases, residents were placed on increased monitoring, such as fifteen-minute checks, following altercations, but the report details that the aggressive behaviors persisted over time. Staff interviews confirmed awareness that resident-to-resident abuse can occur and that such incidents are considered abuse. Staff described monitoring public areas and intervening when altercations occurred, but also acknowledged challenges in preventing these events, especially given the behavioral profiles of the residents involved. Documentation and investigations were completed after each incident, and law enforcement was notified in several cases. However, the repeated nature of the incidents and the direct observations of physical aggression between residents demonstrate a failure to ensure all residents were protected from abuse and physical harm by others.