Failure to Prevent and Monitor Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent and protect multiple residents from abuse and neglect, specifically in cases involving resident-to-resident altercations. On several occasions, one resident with a history of intrusive and aggressive behaviors was able to physically engage with other residents, resulting in injuries. In one incident, this resident approached another in a common area, grabbed him by the shirt, and pulled him from his wheelchair, causing both to fall to the ground. The victim was not exhibiting any provoking behaviors at the time of the incident. Further review revealed that the same resident entered another resident's room on two separate occasions, leading to physical altercations. In one instance, the resident entered a shared room, approached a roommate, and was physically removed by another resident, resulting in a fight. In another incident later that night, after being put to bed and no longer under one-to-one supervision, the resident again entered the same room, leading to a physical confrontation that caused visible injuries, including a laceration near the eye and chest bruising to one of the residents involved. Staff interviews confirmed lapses in supervision, with one staff member noting that the assigned one-to-one monitor was not present when the resident left his bed. The facility's policy required increased supervision and ongoing assessment for residents with behaviors that may lead to conflict, but these measures were not consistently implemented. The lack of adequate monitoring and failure to maintain a safe environment directly contributed to repeated altercations and injuries among residents, demonstrating a breakdown in the facility's abuse prevention protocols.