Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by multiple incidents of resident-to-resident altercations resulting in physical harm or distress. Several residents with cognitive impairments, behavioral disturbances, or psychiatric diagnoses were involved in physical altercations, including punching, hitting, biting, kicking, and other aggressive behaviors. In many cases, care plans identified behavioral risks and interventions, such as redirection or increased supervision, but these measures were not effective in preventing the altercations. Staff were often present or nearby during these incidents but were unable to intervene in time to prevent physical contact or injury. Specific incidents included residents with severe cognitive impairment or behavioral issues engaging in physical fights, such as punching each other in the face, smacking, or dragging another resident by the arm. In some cases, residents sustained visible injuries, such as bruises, bites, or skin discoloration, and required assessment and treatment. Documentation revealed that staff sometimes struggled to separate residents during altercations, and in several instances, altercations lasted for several minutes before staff could intervene. Some residents had a documented history of prior altercations with the same peers, and staff were aware of these patterns. The facility's documentation and interviews with staff and the administrator confirmed that these incidents were considered abuse and required reporting. However, the recurrence of such events, the inability to prevent or promptly stop physical altercations, and the lack of effective interventions to protect residents' rights to be free from abuse constituted a failure to ensure resident safety. The facility was also unable to provide investigation documents for some incidents beyond a 12-month period, indicating gaps in record-keeping related to abuse investigations.