Failure to Prevent and Report Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse, resulting in both residents physically assaulting each other. One resident, with diagnoses including schizophrenia, schizoaffective disorder, and major depressive disorder, reported that another resident entered his room without permission and began taking his food. When confronted, the second resident allegedly struck the first on the head, prompting the first resident to retaliate by punching the second resident multiple times. The first resident also reported feeling unsafe due to a lack of staff presence and stated that staff did not intervene or prevent the incident. The second resident, who also had a history of mental health diagnoses such as schizoaffective disorder and bipolar disorder, confirmed the altercation but stated that he had been given permission to take the food. He reported being punched first and then defending himself by striking back. Both residents had intact cognitive function according to their most recent assessments. Staff documentation and interviews indicated that the incident was not witnessed by staff, and there was no immediate intervention during the altercation. Despite the facility's abuse policy requiring immediate reporting and investigation of abuse allegations, the incident was not reported to the administrator or investigated as required. The psychosocial rehabilitative services director was aware of the altercation but did not report it, as he had not witnessed the event and staff present did not provide details. Social service notes only documented a verbal disagreement, and there was no evidence of a thorough investigation or appropriate follow-up in response to the physical altercation.