Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect multiple residents from physical abuse by other residents, in violation of its abuse prevention policy. In one incident, a male resident with a history of bipolar disorder and dementia struck another male resident with a pair of pliers near the nurse's station. The aggressor had previously found and hidden the pliers, which were not permitted in the facility, and used them during a confrontation. Both residents involved had cognitive impairments, and staff intervened after hearing a commotion. Documentation confirmed that the aggressor was sent to the hospital for evaluation following the altercation. In a separate series of events, another resident with schizoaffective disorder and a history of aggressive behavior physically assaulted two other residents. One resident was struck in the face, resulting in a red mark and bruising, while another was pushed from a wheelchair. Staff and social service notes indicated that the aggressor had a pattern of physical aggression towards peers, and the incidents were witnessed and reported by staff. The aggressor was subsequently sent to the hospital and not permitted to return to the facility. The facility's records, including care plans and risk assessments, documented that the residents involved were at risk for abuse due to their diagnoses and behaviors. Despite these known risks, the facility did not prevent the physical altercations or ensure that residents were free from abuse as required by policy. Staff interviews and documentation confirmed that tools were not allowed in the facility and that the incidents constituted physical abuse.