Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect multiple residents from verbal and physical abuse by other residents, as evidenced by four separate incidents involving different individuals. In one case, a female resident with dementia and severely impaired cognition was slapped in the face by another resident with schizophrenia and vascular dementia while both were in wheelchairs. The care plan for the victim included interventions to assess and document claims of aggression and to separate her from others to ensure safety, but the incident still occurred. The aggressor had a care plan addressing behavioral issues related to schizophrenia, with interventions to protect others and monitor behaviors, yet the physical abuse was not prevented. Another incident involved a female resident with anxiety and depression who was verbally abused by a male resident with a history of traumatic brain injury and behavioral syndromes. The male resident cursed at her and made a distressing comment about her deceased daughter. The care plan for the aggressor acknowledged his potential for verbal and physical aggression and included monitoring and separating him from others, but he was still able to verbally abuse another resident. The victim reported feeling afraid at the time of the incident, although she later stated she felt safe after the aggressor apologized. Additional incidents included a female resident with bipolar disorder being physically grabbed and shaken by the same male resident with behavioral issues, despite staff being present and attempting to intervene. In another case, a female resident who often propelled her wheelchair backward accidentally made contact with a male resident, who then struck her on the arm. Both residents had care plans addressing their behaviors and mobility, but the physical altercation still occurred. These events demonstrate that the facility did not effectively implement measures to prevent abuse between residents, as required by their own policies and care plans.