Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent physical abuse between residents, resulting in two separate altercations involving four residents. In the first incident, two residents with significant physical and mental health diagnoses, including bilateral leg amputations, schizophrenia, anxiety disorder, and traumatic brain injury, were involved in a physical altercation on the back patio. Video footage showed one resident attempting to enter the building while the other was blocking the doorway, leading to a verbal exchange, physical contact, and ultimately one resident punching the other in the face. Staff were present and intervened after the physical abuse occurred. In the second incident, two cognitively intact residents with histories of schizophrenia, schizoaffective disorder, anxiety disorder, major depressive disorder, and PTSD were involved in an altercation in the dining room. The altercation began as a verbal dispute over money, escalating when one resident allegedly pushed the other to the ground. The resident who fell sustained injuries to the nose and left knee. Staff entered the dining room after the incident and separated the residents. It was noted that behavioral monitoring, which should have been in place for one of the residents, was not implemented prior to the incident. Both incidents were confirmed by staff interviews and facility investigation summaries as physical abuse. The facility's policies defined abuse and outlined staff responsibilities for intervention and redirection of residents exhibiting behavioral symptoms. However, in both cases, staff failed to prevent the escalation of resident-to-resident altercations, resulting in physical harm.