Failure to Prevent Resident-to-Resident Physical Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent resident-to-resident physical abuse, resulting in harm from the reasonable person perspective for three residents. One resident with severe cognitive impairment and a history of physical and verbal behaviors was observed becoming confrontational with others in the memory care unit dining hall, attempting to take drinks and becoming upset. Staff attempted redirection, but the resident repeatedly returned to the area and continued the behavior. Incident reports revealed multiple altercations involving this resident, including being physically grabbed and pushed by other residents after entering their personal space or rooms. The care plan for this resident identified a risk for physical aggression and outlined specific interventions, such as 1:1 de-escalation and immediate separation of residents during altercations. Despite these interventions being documented in the care plan, observations and record reviews showed that the interventions were not consistently implemented. The facility's own policy required monitoring for aggressive behavior, prompt reporting, care plan updates, documentation of interventions, and psychiatric consultation as needed. However, the resident continued to be involved in multiple altercations, and staff interviews indicated ongoing issues with supervision, behavioral management, and lack of effective intervention. The facility reported several incidents of resident-to-resident abuse involving the same individuals, and the required care plan interventions were not followed at the time of the observed incidents.