Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect multiple residents from abuse by other residents, as evidenced by several documented incidents of physical altercations. In one case, a resident with severe cognitive impairment and a history of wandering and aggression was bitten on the hand by another resident known to be territorial and prone to agitation when her personal space was invaded. Staff witnessed the incident and intervened to separate the residents, but not before an injury occurred. Both residents had documented behavioral issues and cognitive impairments, and the incident was reported and investigated by the facility. Another incident involved a resident with severe cognitive impairment and a history of physical aggression who was punched in the head by another resident with moderate cognitive impairment and behavioral symptoms. Staff observed the aftermath, noting a visible injury, and interviews revealed ongoing tension between the two residents, with one being protective of his belongings and the other prone to wandering into others' rooms. Staff confirmed witnessing the altercation and described the residents' history of conflict. Additional altercations were documented, including one where a resident was struck in the face during a wheelchair entanglement, resulting in a lip laceration, and another where two residents became verbally and physically aggressive in the dining room, leading to mutual physical contact. Staff interviews confirmed that such incidents were considered abuse and should be reported, and facility policy affirmed residents' rights to be free from abuse. Despite these policies and staff awareness, the facility did not prevent these resident-to-resident altercations, resulting in physical and emotional harm.