Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure an environment free from abuse for seven residents, as evidenced by multiple resident-to-resident altercations involving a resident with Alzheimer's disease and other cognitive impairments. This resident, who exhibited physical and verbal behavioral symptoms directed toward others, was involved in at least eight altercations over a five-month period. The incidents included physical aggression such as hitting, slapping, and pushing other residents, often in response to triggers like loud environments, direct tones, or perceived disrespect. Despite the resident's care plan being updated with new interventions after each incident, these measures did not prevent further occurrences of abuse. Several of the altercations resulted in physical harm or distress to other residents, some of whom also had severe cognitive impairments and were unable to fully understand or recall the events. In one instance, a resident was struck on the head after yelling at the aggressive resident, while in another, a resident was punched in the chin and fell, sustaining a cut. Other incidents involved residents being hit during meals or in common areas, leading to fear, anxiety, and psychosocial distress among the victims. Staff interviews confirmed that the interventions in place, such as redirection, engagement, and intermittent 1:1 support, were not consistently effective or documented, and the day room was not always monitored as required. The facility's own policy required appropriate steps to prevent harm from resident-to-resident altercations, but staff acknowledged that supervision and interventions were not always consistently implemented or documented. Staff shortages and competing demands sometimes made it difficult to provide the necessary supervision, and 1:1 support was provided only intermittently or after incidents occurred. As a result, the environment was not free from abuse, and residents continued to be exposed to the risk of physical and psychological harm.