Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse involving two residents. One resident, with a history of chronic medical and psychiatric conditions including PTSD and major depressive disorder, was involved in an altercation with another resident who had paraplegia and a documented pattern of physical and verbal aggression. The incident occurred when several residents attempted to use the elevator at the same time, leading to one resident attempting to forcibly remove a female resident in a wheelchair to gain access. The other resident intervened, resulting in both residents physically striking each other and falling to the floor before being separated by staff. Documentation and interviews revealed that the aggressive resident had a history of daily physical and verbal aggression, including attacking staff, using foul language, and rejecting care. Despite these ongoing behaviors, the facility did not implement additional safety measures such as placement in a secured unit, citing the resident's refusal and status as his own responsible party. The facility had planned to present a behavior contract at a care plan conference, but the resident was discharged to a psychiatric unit before this could occur. The facility's abuse policy required protection of residents and review of risk factors, but the incident was not substantiated as abuse by the facility due to uncertainty about who initiated the altercation. The facility's records did not list witnesses or identify a perpetrator for the incident, and the administrator confirmed that the allegation of abuse was unsubstantiated. The aggressive resident was eventually given an immediate discharge notice and escorted from the property by police after returning from the hospital against medical advice. The facility's failure to implement effective interventions to address the known aggressive behaviors contributed to the occurrence of resident-to-resident physical abuse.