Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents' rights to be free from resident-to-resident physical abuse, as evidenced by multiple documented incidents involving one resident making physical contact with several other residents. According to the facility's own investigations, one resident was involved in repeated incidents where they entered other residents' rooms, went through their belongings, and made physical contact with their hands, wrists, and forearms. These incidents were reported by both staff and residents, and the facility's investigations confirmed that the events occurred as described. Staff interviews and record reviews further confirmed that the same resident was known to have been involved in multiple abusive incidents affecting at least three other residents. The incidents occurred in various settings, including during one-to-one care and while other residents were engaged in activities such as playing cards. The facility's abuse prevention program states that residents have the right to be free from all forms of abuse, but the repeated nature of these incidents demonstrates a failure to uphold this standard for the affected residents.