Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical and psychosocial harm, resulting in two residents being physically assaulted by another resident with a known history of aggressive behaviors. One resident, who had severe cognitive impairment and a documented history of physical aggression, entered another resident's room and struck them multiple times, causing visible bruising. Staff interviews and incident reports confirmed that the aggressive resident was able to access the victim's room and physically assault them before staff intervened. The assaulted resident reported feeling scared and in pain, and staff observed a bruise and redness on the resident's arm and face following the incident. In a separate incident, the same aggressive resident entered another resident's room, took their cane, and struck them repeatedly on the legs, resulting in multiple bruises. The victim, who also had severe cognitive impairment, reported being shocked and fearful after the attack, expressing that they no longer felt safe moving freely within the facility. Staff and witness statements confirmed that the aggressive resident was able to take the cane and use it as a weapon before being removed from the room by staff. The victim was found to have several bruises on their right leg and knee following the incident. Both incidents involved a resident with a known risk for aggression and wandering, as documented in their care plan and staff interviews. Despite this, the resident was able to access other residents' rooms and inflict harm. The facility's failure to implement effective interventions to prevent these assaults resulted in physical injuries and emotional distress for the victims. The facility's abuse policy requires immediate reporting and investigation of abuse, but the report indicates that not all incidents were reported as required, and staff responses varied regarding the timeliness and adequacy of interventions to prevent further harm.