Failure to Prevent and Respond to Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from all forms of abuse, specifically resident-to-resident physical abuse, as evidenced by multiple incidents involving several residents. In one case, a resident with severe cognitive impairment and limited mobility was physically assaulted by his roommate, who had a known history of aggressive behavior. Despite the facility's awareness of the perpetrator's behavioral risks, the two residents continued to share a room, and there was no documentation that the victim or his representative was informed in a language they could understand about the option to move rooms. The victim sustained physical injuries and experienced pain, and the full extent of psychosocial harm could not be determined due to communication barriers. Additional incidents included a witnessed altercation between two other residents, where one punched the other in the hallway after a verbal dispute, and another case where a resident kicked his roommate during an argument over a wheelchair. In both cases, the facility's investigative reports failed to substantiate abuse despite eyewitness accounts and documentation in progress notes that confirmed physical aggression occurred. Furthermore, there was a lack of adequate supervision during a verbal and physical altercation between two residents in a common area, as staff left the area unsupervised, leaving residents in an unsafe environment. The facility's documentation and investigative practices were inconsistent and incomplete, with missing or inadequate records of incidents, lack of communication with residents and their families, and failure to follow policies designed to prevent and prohibit abuse. The facility did not take immediate and appropriate steps to protect residents from further harm once abuse was identified, nor did it ensure that residents with known behavioral risks were managed in a way that prevented recurrence of abuse.