Failure to Protect Residents from Physical Abuse by Peers
Penalty
Summary
The facility failed to protect multiple residents from physical abuse by other residents, resulting in both physical and psychosocial harm. One resident with severe neurocognitive disorder and a history of aggressive behaviors physically assaulted several other residents on multiple occasions. In one incident, this resident grabbed another resident by the neck and pushed her, and in another, pushed a resident to the floor, causing a sprained ankle that required an ER visit and immobilization. A third incident involved the same resident dragging another resident out of his room and pinning her to the floor, resulting in visible discoloration and distress. These incidents occurred despite the known behavioral risks and cognitive impairments of both the aggressor and the victims, who were all severely cognitively impaired and prone to wandering into other residents' rooms. Another incident involved a resident with paraplegia and no cognitive impairment who was physically assaulted by his roommate. The aggressor verbally threatened and then struck the resident on the face, causing scratches and distress. The assaulted resident was unable to defend himself due to his physical limitations. Staff observed the injuries and confirmed the account, and the incident was reported to the appropriate authorities. The aggressor denied the physical assault but admitted to a verbal altercation. In all cases, the facility's actions and interventions prior to the incidents were insufficient to prevent the abuse, despite documented behavioral risks and prior aggressive incidents. The facility's policies required the protection of residents from abuse, but the measures in place did not prevent repeated harm to vulnerable residents. Staff interviews confirmed that the aggressive behaviors were known, and interventions such as redirection of wandering residents were inconsistently effective. The facility did not implement increased supervision or one-to-one monitoring for the resident with repeated aggressive incidents, and documentation of efforts to find alternative placement after discharge notices was lacking.