Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect three residents from physical abuse, resulting in multiple incidents of resident-to-resident altercations. In one incident, two residents were involved in a physical altercation on the patio, where one resident punched another in the face twice, and the other retaliated by striking back. Witnesses confirmed the sequence of events, and both residents had documented histories of behavioral issues, including aggression and impaired cognitive function. The care plans for these residents noted their tendencies toward verbal and physical aggression, but the interventions in place did not prevent the altercation from occurring. In a separate incident, another resident made a derogatory comment to a peer in the dining room, prompting the peer to grab and pull the resident's hair. This event was witnessed by staff and another resident, and the staff member intervened to stop the physical contact. The resident who initiated the hair-pulling had a documented history of poor impulse control and aggression, and the victim was also known to use derogatory language and display verbally aggressive behavior. Despite these known risks, the care plan for the aggressor was not revised until several days after the incident. Staff interviews revealed that employees were aware of the behavioral challenges and triggers among the residents involved. Staff described expectations to monitor residents closely and intervene when agitation or altercations were observed. However, the facility's actions and existing interventions were insufficient to prevent the physical abuse incidents, as evidenced by the repeated altercations and the lack of timely updates to care plans following the events.