Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by other residents. In the first incident, a resident with heart failure and generalized weakness was struck twice in the head by her roommate after waiting outside the bathroom. The resident reported pain and distress following the incident. Documentation and interviews revealed that the aggressor had previously been on 1:1 observation for behavioral concerns, but this supervision was not provided during the night shift when the incident occurred. The Director of Nursing confirmed that 1:1 observation was not guaranteed during night shifts, and the aggressor did not have a sitter at the time of the event. In the second incident, a resident with respiratory failure and chronic pain syndrome had lemonade thrown at her by her roommate, who exhibited ongoing verbal and physical aggression. Staff responded to the altercation after hearing screaming and separated the residents. Documentation indicated that the aggressor continued to display aggressive behaviors in the days following the incident, ultimately resulting in a psychiatric hold. In both cases, the facility's investigations concluded the events as negative interactions between residents, and the facility's abuse prevention policy required the identification and intervention in situations where abuse was more likely to occur.