Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by an incident involving two cognitively intact residents with multiple medical and psychiatric diagnoses. One resident reported being grabbed by the throat by their roommate during a confrontation in the hallway near the smoking area. Multiple interviews confirmed that the altercation occurred, with one resident admitting to grabbing the other's throat after becoming aggravated by ongoing complaints. Several witnesses, including staff and other residents, observed or heard the commotion and confirmed the physical contact. Staff responded to the incident by separating the residents and assessing for injuries, but there were no visible marks or signs of injury. The only immediate action taken was moving the resident who initiated the physical contact to a different room. The incident was reported to the facility administrator and abuse prevention coordinator, and staff acknowledged awareness that the event constituted abuse. The facility's policy affirms residents' rights to be free from abuse, neglect, and mistreatment, but the actions taken did not prevent the occurrence of physical abuse between residents.