Failure to Protect Residents from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect multiple residents from physical abuse by another resident, resulting in several incidents where residents were pushed, hit, or kicked. In one incident, a resident with severe cognitive impairment and poor impulse control pushed another resident in the dining room, causing her to fall to the ground. The victim was startled and confused but did not sustain visible injuries. The assailant had a documented history of similar behaviors, including a prior physical occurrence, but did not have a behavior care plan at the time of the incident. Staff interviews and record reviews confirmed that the resident's behaviors were known to be unpredictable and triggered by crowded areas, particularly around the coffee station and during smoking breaks. Another incident involved the same resident pushing and hitting a different resident who was blocking his way to the smoking area. Multiple staff and resident interviews confirmed that the assailant became quickly agitated and used physical contact to move others out of his way. Despite these repeated behaviors, the facility's investigations often concluded that the incidents were unsubstantiated as abuse due to the absence of injury, pain, or fear in the victims. However, documentation and witness statements indicated that physical aggression did occur, and the assailant's behaviors were recognized by staff as a recurring issue. A third incident involved the same resident kicking another resident in the leg to get him out of the way at the coffee station. Staff and resident interviews, as well as progress notes, confirmed the physical contact, but again, the facility did not substantiate the incident as abuse due to lack of injury or fear. The assailant's care plan included interventions such as offering coffee, anticipating needs, and keeping other residents clear of him, but not all staff were aware of his triggers. The repeated failure to prevent these incidents and to recognize them as abuse led to the deficiency cited in the report.