Failure to Prevent Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in a physical altercation between them in their shared room. Both residents alleged that the other initiated the altercation and admitted to hitting each other in the face in self-defense. Staff assessments found one resident with a small abrasion on the lip and the other with a swollen lip. The facility's policy on abuse prevention required staff to identify, correct, and intervene in situations where abuse is more likely to occur, including understanding behavioral symptoms that may increase the risk of abuse. Medical record reviews revealed that one resident had a documented history of physically aggressive and assaultive behaviors, including multiple incidents of verbal threats, striking staff, punching walls, and previously striking another resident. The other resident also had a care plan for aggressive behavior, with documented episodes of agitation, responding to internal stimuli, threatening staff, and physical aggression such as punching walls and plexiglass. Interviews with facility leadership and the residents confirmed ongoing behavioral issues, including command hallucinations and medication changes that may have contributed to escalating behaviors prior to the altercation.