Failure to Prevent Resident-to-Resident Abuse and Neglect
Penalty
Summary
The facility failed to protect multiple residents from various forms of abuse, including physical and sexual abuse, as well as neglect, as evidenced by several documented resident-to-resident altercations. In one incident, a resident with moderate cognitive impairment and a history of sexually inappropriate behavior was observed pushing a female resident with severe cognitive impairment against a wall and fondling her breasts in a common area. Staff and other residents reported that the female resident appeared frightened and expressed fear of the male resident, who had previously exhibited similar behaviors. Despite care plan interventions to prevent unsupervised contact, the incident occurred, and both residents were interviewed regarding the event. In other cases, residents with behavioral and cognitive impairments engaged in physical altercations resulting in injuries. For example, one resident struck another in the face multiple times in a dayroom altercation, with both residents having documented histories of aggression and care plans indicating the need for close monitoring and separation. Another incident involved a resident hitting a peer in the head over a dispute about a television remote, with witnesses and staff confirming the aggressive behavior. Additional altercations included a resident attacking a roommate, resulting in bleeding and emergency medical intervention, and another resident causing facial injuries to a peer who wandered into his room. The report details that in each of these cases, the facility's interventions, such as care plans for behavioral management and monitoring, were either insufficient or not effectively implemented to prevent abuse. Staff interviews confirmed awareness of the residents' behavioral risks and the definitions of abuse, but the incidents still occurred, indicating lapses in supervision and protection. Facility policies reviewed defined abuse broadly, including physical, sexual, and verbal abuse, and emphasized the right of residents to be free from such harm, yet the documented events demonstrate that these standards were not upheld in practice.