Failure to Prevent Resident-to-Resident Abuse in Unsupervised Common Areas
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by multiple resident-to-resident altercations that resulted in physical and emotional harm. In one incident, a resident with schizoaffective disorder and moderate cognitive impairment was involved in an altercation with another resident, during which both used their wheelchairs as weapons and physical blows were exchanged. The altercation began as a verbal dispute inside the building and escalated on the patio, where there was no staff supervision. Witnesses confirmed the physical nature of the altercation, and the facility's investigation determined that both residents were active participants. Staff interviews revealed that residents were allowed to access the patio and smoke without supervision, and staff typically became aware of incidents only when informed by other residents. Another incident involved two residents in the designated smoking area, where one resident was observed throwing rocks at cats. When confronted by another resident, the situation escalated to physical violence, with one resident hitting the other in the face and tearing their shirt. Security footage confirmed the sequence of events, and the injured resident exhibited physical signs of distress, including redness on the face and anxiety. Staff interviews consistently identified such resident-to-resident altercations as abuse according to facility policy, which defines abuse as the willful infliction of injury or pain. A third altercation occurred between two residents following a verbal disagreement, which escalated to both residents throwing coffee at each other, and one resident being struck in the face with a mug. Staff and resident interviews confirmed the altercation and described ongoing behavioral issues between the involved residents. Facility policy and staff statements consistently recognized these interactions as abuse. In all cases, the lack of supervision in common areas such as the patio and smoking area contributed to the occurrence and escalation of these incidents.