Failure to Prevent and Address Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its policies and procedures prohibiting abuse, neglect, and exploitation for all 19 residents reviewed for abuse/neglect. Multiple incidents of resident-to-resident abuse occurred, including physical, verbal, and sexual abuse, as well as altercations resulting in injuries such as a fractured hip. The facility's own incident logs and progress notes document repeated episodes where residents with significant cognitive and behavioral impairments engaged in aggressive or inappropriate behaviors toward other residents. In several cases, care plans either did not address these behaviors or interventions were not effective in preventing further incidents. Specific events included a resident groping another, a resident slapping an unidentified peer, and several instances of residents physically assaulting each other with objects or by hand. In one case, a resident was pushed to the floor and sustained a hip fracture, while in another, a resident attempted to stab another with a fork. There were also episodes of verbal abuse, such as screaming and cursing, and repeated attempts by one resident to kiss other residents inappropriately. The documentation shows that staff were aware of these behaviors, and in some cases, attempted to intervene or notify medical and administrative personnel, but the actions taken did not prevent recurrence. The residents involved had complex medical and psychiatric histories, including severe cognitive impairment, dementia, schizophrenia, bipolar disorder, and other behavioral disturbances. Despite these known risks, the facility did not consistently update care plans to address aggressive or inappropriate behaviors, nor did it implement effective interventions to protect residents from harm. The failure to follow established policies and procedures resulted in multiple residents being subjected to abuse and physical harm, as evidenced by the facility's own records and staff interviews.