Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect multiple residents from episodes of physical abuse perpetrated by other residents. Several incidents were documented in which residents with cognitive and psychiatric diagnoses engaged in physical altercations, resulting in injuries. In one instance, a female resident with schizoaffective disorder and intact cognition was struck on the jaw by a male peer with Alzheimer's disease and moderate cognitive impairment while she was in her wheelchair in the hallway. Witness statements confirmed that the male resident became agitated, yelled, and hit the female resident with a closed fist. No injuries were noted, and the resident denied pain or discomfort at the time. Another incident involved a cognitively intact female resident with multiple psychiatric diagnoses who was pushed to the ground by a male resident with moderate cognitive impairment during a struggle over snacks in the dining room. The female resident sustained a displaced fracture of the distal radial metaphysis in her right wrist, as confirmed by x-ray. Witnesses, including a registered nurse, observed the altercation and confirmed that the male resident pushed the female resident after both attempted to take possession of the snack. The injured resident later reported significant pain in her wrist. Additional altercations were documented, including an incident in which a female resident attempted to take another resident's belongings, resulting in a physical confrontation where one resident was pushed and then struck in the face. Another event involved a resident being pushed to the ground after reaching for another resident's cup. These repeated episodes of resident-to-resident physical abuse occurred despite the facility's abuse prevention policy, which affirms residents' rights to be free from abuse and outlines the facility's commitment to preventing mistreatment. The documented incidents demonstrate a failure to prevent and protect residents from physical abuse by peers.