Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect multiple residents from physical abuse by peers, resulting in several incidents where residents were physically hit, pushed, or punched by other residents. In one case, a resident with a history of schizophrenia, bipolar disorder, and mobility issues was struck and pushed by another resident, leading to a fall and a laceration on the forehead that required eight stitches. The incident occurred when the aggressor confronted the victim over alleged theft, and no staff were present at the time to intervene. The staff became aware of the situation only after the injury had occurred, and the nurse on duty was not on the floor during the incident. In another incident, a resident reported being hit by another resident who wandered into their room. The staff responsible for monitoring the residents was on a lunch break and did not inform the nurse, leaving the floor without adequate supervision. The nurse was at the nurse's station and did not witness the altercation, only becoming aware after hearing a commotion. Both residents involved were later hospitalized. The facility's protocol for staff coverage during breaks was not effectively implemented, resulting in a lack of monitoring for residents known to require close supervision. Additional incidents included a resident being hit in the back of the head by another resident while lining up for a smoke break, and a resident physically attacking their roommate while on one-to-one monitoring for behavioral issues. In these cases, staff either witnessed the aftermath or were present but unable to prevent the abuse. The facility's policies on abuse prevention and behavior management were not adequately followed, as residents who posed a risk to others were not consistently separated or monitored to prevent harm.