Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to provide an environment free from mental and physical abuse for a resident with severe cognitive impairment, Alzheimer's disease, dementia, and anxiety disorder. This resident experienced multiple incidents of abuse from other residents, all of whom also had severe cognitive or behavioral impairments. On several occasions, altercations occurred in common areas, including one incident where a resident was punched multiple times, another where slapping occurred between two residents, and a third where a resident was tipped backward in a wheelchair and sustained a large hematoma to the head requiring emergency room care. These events were captured on facility video footage and confirmed by administrative staff interviews. The facility's own policy stated that residents must not be subject to abuse by anyone, including other residents. Despite this, staff failed to adequately supervise the residents and did not implement interventions to prevent repeated mental and physical abuse. The lack of effective supervision and intervention allowed for ongoing resident-to-resident altercations, resulting in fear, anxiety, and physical injury to the affected resident.