Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect three residents from physical abuse by their roommates, resulting in multiple incidents of resident-to-resident altercations. In one case, a cognitively intact resident with paraplegia and other significant diagnoses was attacked by her roommate, who attempted to use scissors as a weapon and struck her with a call light. The incident was witnessed by a restorative aide, who intervened and removed the scissors, but the aggressor produced a second pair of scissors after the initial intervention. The victim expressed ongoing feelings of being unsafe following the event. Another incident involved two residents with cognitive and behavioral health diagnoses who engaged in a physical altercation, described as wrestling on a bed. The altercation was reported by a roommate and confirmed by an LPN who intervened. A body check revealed redness, and a police report was filed for simple battery. The care plan for one of the residents documented a potential for abuse or neglect. A third incident involved a resident with legal blindness and multiple comorbidities who was kicked by his cognitively intact roommate. The victim reported feeling upset and helpless due to his inability to defend himself. Staff were notified, and the aggressor admitted to the action, stating it was due to having a bad day. The facility's documentation and interviews confirm that these resident-to-resident altercations occurred, and the affected residents were identified as being at risk for abuse and neglect in their care plans.