Failure to Prevent Resident-on-Resident Abuse and Inadequate Supervision
Penalty
Summary
The facility failed to protect two residents from abuse by another resident with a known history of physical aggression. Resident 82, who had diagnoses including dementia with behavioral disturbance and anxiety, exhibited aggressive behaviors such as intrusive wandering and physical aggression. Despite these known risks, the facility did not maintain adequate supervision or implement sufficient interventions to prevent Resident 82 from physically assaulting other residents. The first incident involved Resident 82 placing his arms around the neck of another resident in the television lounge, which was witnessed by staff and resulted in staff intervention. Following this initial event, Resident 82 continued to display aggressive behaviors, including yelling, cursing, and unsuccessful redirection attempts by staff. A second incident occurred when Resident 82 grabbed another resident by the neck and pushed him, resulting in visible redness on the resident's neck. This incident was reported by the victim and corroborated by staff documentation, yet the facility did not substantiate the abuse allegation, citing a lack of direct staff witnesses despite physical evidence and consistent resident statements. The facility's failure to provide consistent and adequate supervision for Resident 82, despite his documented history of aggression and psychiatric recommendations, led to repeated incidents of physical aggression and emotional distress for other residents. The facility also failed to substantiate abuse allegations in the presence of physical signs of injury and credible witness statements, further contributing to the deficiency.