Failure to Prevent Repeated Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from repeated physical abuse by another resident, resulting in injury. Multiple incidents of resident-to-resident aggression occurred between two residents, both of whom were cognitively intact according to their Brief Interview for Mental Status (BIMS) scores. Despite ongoing abusive interactions, including physical altercations such as hitting, slapping, and use of objects to inflict harm, the facility did not implement effective interventions to prevent further abuse. Staff were aware of the ongoing relationship and history of aggression between the two residents, but hourly monitoring and room changes did not prevent the incidents, as the residents continued to seek each other out. Documentation and interviews revealed that staff, including CNAs, LPNs, and the Social Services Director, were aware of multiple incidents over several months. These included physical assaults resulting in visible injuries such as periorbital edema and redness to the eye, which required pain medication. The facility's policy required the prevention of abuse and the provision of a safe environment, but staff did not escalate supervision or consider one-on-one monitoring, even after repeated events. There was also a lack of consistent documentation for all incidents, and some staff could not recall if incident reports were completed. The residents involved had significant medical histories, including hemiplegia, diabetes, chronic kidney disease, and heart failure. Both residents had been referred to psychiatric and psychosocial services, and discharge planning was underway for one resident. However, these actions did not prevent further abuse prior to the most recent incident. The facility's failure to implement effective measures to separate or supervise the residents resulted in continued physical harm and did not uphold the residents' right to be free from abuse.