Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect multiple residents from physical abuse, resulting in several substantiated incidents involving resident-to-resident altercations. Four residents were directly affected, with repeated episodes of physical aggression primarily involving one resident with a history of severe cognitive impairment, aggressive behaviors, and complex psychiatric diagnoses. This resident exhibited unpredictable and escalating behaviors, including yelling, hitting, pushing, and slapping other residents, as well as self-injurious actions such as hitting herself and pulling her own hair. The care plans for this resident identified a history of trauma, severe dementia, and behavioral disturbances, with interventions in place for both pharmacological and non-pharmacological management. Despite these interventions, the resident continued to engage in aggressive acts toward others, including dumping water, slapping, pushing, and grabbing, which resulted in physical harm to other residents, such as bruises and a skin tear. Other residents involved in these incidents also had significant cognitive impairments and behavioral symptoms, with care plans outlining interventions for managing aggression and agitation. In several cases, altercations occurred in common areas under staff supervision, but staff were unable to prevent or effectively de-escalate the situations before physical contact occurred. The facility's own investigations substantiated the allegations of abuse, documenting that the aggressive resident was the primary assailant in multiple incidents. Environmental factors, such as overstimulation in the memory care unit and busy periods after meals, were identified as contributing to the escalation of aggressive behaviors. Staff interviews confirmed the unpredictability of the aggressive resident's actions and the challenges in redirecting her, even with individualized interventions and education provided to staff. The facility's abuse policy emphasized the importance of providing a safe environment and preventing abuse by anyone, including other residents. However, the repeated incidents of physical abuse, the inability to prevent resident-to-resident altercations, and the failure to consistently implement effective interventions led to multiple residents being subjected to physical harm. The documentation and interviews revealed that staff were aware of the risks and had attempted various strategies, but these were not sufficient to prevent the substantiated episodes of abuse.