Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect residents from abuse, resulting in two separate incidents involving resident-to-resident altercations. In the first incident, a male resident with severe cognitive impairment and psychiatric diagnoses was physically assaulted by his roommate. The altercation escalated from verbal arguments to physical violence, with the aggressor striking the resident with a ruler multiple times and then stabbing him with a pen, causing scratches and lacerations to the abdomen and neck. The assaulted resident was found on the floor in a disheveled room, exhibiting signs of emotional distress and physical injury, and was subsequently sent to the hospital for evaluation. Staff interviews confirmed that the altercation was not witnessed, but the aftermath indicated significant violence had occurred. In the second incident, a female resident with severe cognitive impairment, a history of hip fracture, and impaired mobility was pushed by another resident while standing near a wheelchair in a common area. This resulted in the resident falling and sustaining a left hip fracture and left wrist fracture, requiring hospitalization and surgery. Staff accounts indicated that the aggressor had a known history of aggressive behavior and required frequent redirection and monitoring. The incident was witnessed by staff, who responded after hearing raised voices and observed the resident in pain with an obvious injury. Both incidents involved residents with known behavioral or cognitive issues, and in each case, the facility did not prevent the altercations that led to physical harm. The facility's failure to ensure adequate supervision, monitoring, and intervention allowed these resident-to-resident altercations to occur, resulting in injury, hospitalization, and emotional distress for the affected residents. The events were substantiated through observation, interviews, and record reviews, confirming that the residents were not protected from abuse as required.