Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect multiple residents from physical abuse, neglect, and exploitation, as evidenced by several substantiated incidents of resident-to-resident altercations. In at least six cases, residents with known histories of behavioral disturbances, cognitive impairment, or impulse control issues physically assaulted other residents. These incidents occurred in common areas such as hallways, often when staff were not present to monitor or intervene. In some cases, video surveillance captured the altercations, and staff responded after the fact, but the lack of immediate supervision allowed the incidents to occur. Residents involved in these altercations had documented behavioral care plans identifying their potential for aggression and specific triggers, such as invasion of personal space, waiting for meals, or agitation when others entered their rooms. Despite these care plans, interventions were not always sufficient to prevent physical altercations. For example, one resident with dementia and behavioral disturbances struck another resident after a perceived invasion of personal space, while another resident with a history of aggression hit a peer in the hallway after being followed too closely. In several cases, the victims experienced pain or distress, and in one instance, a resident fell and required X-rays to rule out fractures. Staff interviews revealed that hallways were not consistently monitored, especially when CNAs were providing care in resident rooms or on breaks. Although the facility had video surveillance, it was not continuously monitored, and staff relied on periodic checks or responded to incidents after they occurred. Staff were aware of residents with aggressive behaviors and had received training in abuse prevention and de-escalation, but the lack of consistent supervision and immediate intervention contributed to the failure to prevent resident-to-resident abuse.