Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident, resulting in two separate incidents of resident-to-resident physical altercations. In the first incident, a resident with severe cognitive impairment and a history of agitation and psychotic disorder initiated a verbal altercation with another cognitively impaired resident in a common area. Despite staff presence, the aggressive resident struck the other on the back of the head, an act witnessed by staff. The victim was left teary-eyed but did not sustain physical injuries. The aggressive resident had a recent reduction in antipsychotic medication, which was later increased after the incident due to a return of behavioral issues. In the second incident, the same aggressive resident was involved in a physical altercation with a different roommate, also diagnosed with severe dementia and behavioral disturbances. The altercation occurred in their shared room, where the aggressive resident slapped the roommate on the face, resulting in visible redness and emotional distress. The aggressive resident claimed provocation, but the victim denied any physical aggression. Staff responded to the incident after hearing a scream and found the victim holding her face and visibly upset. The incident was documented, and the residents were separated immediately after. Both incidents were substantiated or under investigation by the facility, with staff interviews confirming the aggressive resident's history of agitation, confrontational behavior, and recent emotional distress related to personal matters. The facility's policy prohibits all forms of abuse, including resident-to-resident abuse, but the interventions in place failed to prevent these incidents. The events were witnessed by staff, and the facility's documentation confirmed the occurrence of physical abuse between residents.