Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by two separate altercations involving four residents. In the first incident, one resident with severe cognitive impairment and multiple medical diagnoses, including atherosclerotic heart disease and vascular dementia, was pushed and hit on the back by another resident who was frustrated by the former's slow movement. The aggressor had a history of behavioral episodes and moderate cognitive impairment, but there was no documentation of aggressive behaviors toward others in his assessment. Staff interviews revealed that the incident was witnessed and reported, but staff expressed uncertainty about how to prevent such incidents, citing the speed at which the altercation occurred. In the second incident, two other residents were involved in a physical altercation over a pair of sunglasses. One resident, with severe cognitive impairment and a history of verbal aggression, entered the dining room wearing sunglasses belonging to another resident. After a confrontation, the resident with the sunglasses smashed them on the table, prompting the other resident, who had moderate cognitive impairment and a history of behavioral issues, to physically strike him. Staff present at the scene intervened after the altercation had already escalated, and interviews indicated that staff were unsure of what could have been done differently to prevent the incident. Both residents involved had documented behavioral concerns in their care plans, but interventions primarily focused on redirection and medication review. Record reviews and staff interviews confirmed that the facility had provided abuse and neglect training to staff and maintained an abuse policy with key components such as screening, training, prevention, identification, investigation, protection, and reporting/response. However, despite these measures, the facility did not ensure that residents were free from abuse, as evidenced by the occurrence of these altercations and the lack of effective preventive interventions documented or described by staff.