Failure to Prevent Resident-to-Resident Abuse and Ensure Supervision
Penalty
Summary
The facility failed to protect a resident's right to be free from physical and verbal abuse by not adequately separating and supervising two residents after a physical altercation. One resident, who had a history of schizoaffective disorder, cognitive impairment, and lacked decision-making capacity, struck another resident during a disagreement about a curtain. Staff responded by separating the residents and moving the aggressor to another room, but did not ensure continuous supervision. Despite being moved, the aggressor was able to return to the original room, where further verbal threats were made toward the other resident. Staff interviews revealed lapses in communication and supervision, as well as a lack of immediate follow-up documentation regarding the second incident. The aggressor was not properly monitored, allowing for a second encounter that resulted in additional verbal abuse and threats. The resident who was the victim of the altercation reported feeling unsafe due to the repeated access of the aggressor to the shared room. Staff acknowledged that the residents should have been completely separated and that the second incident was not properly documented or communicated to the physician. The facility's policy prohibits all forms of abuse, but the actions taken were insufficient to prevent further abuse and ensure resident safety.