Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse when a severely cognitively impaired male resident engaged in multiple aggressive incidents toward other residents. The male resident, who had diagnoses including chorea, cerebral palsy, anxiety disorder, and autistic disorder, was documented as having displayed verbal and physical behavioral symptoms directed toward others. Despite being assigned one-on-one supervision, he was able to grab a female resident by the hair on two separate occasions, causing pain and a scratch, and required intervention by multiple staff members to be separated from the victim. Further incidents involved the same male resident physically aggressing toward two additional residents. In one case, he scratched a resident under the eye while attempting to adjust her glasses, and in another, he entered a resident's room and pressed his thumbs into the resident's eyes, resulting in a corneal abrasion that required hospital treatment. The affected residents had significant cognitive and physical impairments, including spastic quadriplegic cerebral palsy, muscular dystrophy, and dependence for all activities of daily living. Staff interviews and clinical documentation confirmed that the male resident's aggressive behaviors were witnessed on multiple occasions, and that the victims experienced pain, injury, and emotional distress. The facility's policy stated that residents have the right to be free from abuse, but the documented events show that the facility did not effectively prevent or intervene to stop repeated physical abuse among residents.