Failure to Prevent Resident-to-Resident Abuse and Inadequate Staff Education
Penalty
Summary
The facility failed to protect residents from verbal and physical abuse by other residents, as evidenced by multiple incidents involving residents with cognitive and behavioral disturbances. In one case, a resident with dementia and behavioral symptoms verbally threatened another resident, who responded by physically grabbing the first resident around the neck and pinning them against the wall. Staff intervened to separate the residents, and no injuries were reported. Prior to this incident, there was no documented history of aggression between these residents, but the facility's response to the altercation was limited in scope, as not all staff received education on managing such behaviors. In another incident, a resident with a history of borderline personality disorder and depression, after returning from a hospital evaluation for suicidal ideation, threw a remote control at their roommate, resulting in a bruise to the roommate's face. The roommate reported ongoing verbal abuse and agitation from the resident prior to the physical altercation. Staff and another resident witnessed the event, and the injured resident was assessed and requested a room change. The resident who threw the remote had previously exhibited emotional distress and was evaluated by hospital staff before returning to the facility. The facility's policies define abuse as the willful infliction of injury or intimidation, including resident-to-resident altercations, and require ongoing assessment and care planning to prevent such incidents. However, the events described indicate that the facility did not adequately identify, monitor, or intervene to prevent resident-to-resident abuse, nor did it ensure that all staff were educated on recognizing and managing behaviors that could lead to conflict or harm.