Failure to Protect Residents from Physical Abuse by Aggressive Resident
Penalty
Summary
The facility failed to protect multiple residents from physical abuse by another resident with a documented history of aggressive behaviors. Several incidents occurred in which a resident with severe vascular dementia and significant cognitive impairment physically assaulted other residents, including hitting, choking, and entering their rooms to take personal belongings. These altercations resulted in emotional distress, fear, and physical harm, such as pain and reddened marks on the necks of the affected residents. Staff interviews and medical records confirmed that the aggressive resident had a pattern of physical and verbal aggression toward others, and that other residents were fearful of further harm. Despite repeated incidents, staff did not consistently implement or document effective interventions to prevent further abuse. Care plans for the aggressive resident were updated reactively after each event, but interventions such as 1:1 supervision were not maintained continuously, and staff reported that redirection was not always successful. There was a lack of clear, resident-centered guidelines for managing the resident's behaviors, and staff did not receive comprehensive or consistent education on how to address these situations. Documentation of staff education was incomplete, with attendance records showing that only a fraction of the required staff participated. The facility's own policy required proactive identification, correction, and intervention in situations likely to lead to abuse, including the assessment and care planning for residents with aggressive behaviors. However, the facility did not ensure that all staff were trained or that interventions were consistently implemented and evaluated. As a result, residents continued to be exposed to the risk of physical abuse, and some experienced repeated incidents of harm and emotional distress.