Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
Facility staff failed to protect a resident from being physically struck by another resident on two separate occasions. The incident occurred when a resident with severe cognitive impairment, Huntington's disease, and a history of aggression reached out and hit another resident with moderate cognitive impairment and Alzheimer's disease as the latter wandered past the aggressor's doorway. Staff immediately separated the residents after the first incident. While staff were redirecting the resident who had been struck, the aggressive resident managed to come around staff and struck the same resident again, twice, with a closed fist to the chest. The aggressive resident had documented behavioral issues, including aggression toward others and accusations against staff, and was supposed to be on frequent checks and in sight of two staff members at all times. Despite these interventions, the second physical altercation occurred in the presence of staff. Interviews with staff confirmed that the aggressive resident was able to leave their room and physically assault the other resident a second time, even after the initial separation. Documentation and staff statements indicate that the aggressive resident's care plan included measures to monitor and manage aggressive behaviors, but these were not sufficient to prevent the repeated physical altercations.