Failure to Prevent Resident-to-Resident Abuse and Neglect
Penalty
Summary
The facility failed to protect multiple residents from abuse and neglect, as evidenced by a series of resident-to-resident altercations involving individuals with severe cognitive impairments and behavioral issues. Several incidents occurred in which residents with dementia and wandering behaviors entered other residents' rooms, leading to physical altercations. In one instance, a male resident with dementia and a history of wandering entered another resident's room and began rummaging through personal belongings, resulting in a physical fight where both sustained minor injuries. Staff interviews confirmed that the resident was known to wander and should have been monitored to prevent such incidents, but monitoring was insufficient at the time. Another incident involved a resident with severe cognitive impairment and behavioral symptoms who was found holding another resident against the wall and hitting him in the face after the latter entered his room and refused to leave. The altercation resulted in visible injuries, including a scratch and swelling, and required staff intervention. Staff accounts indicated that only one CNA was present on the unit at the time, as the other was on break, leaving the area inadequately supervised. This lack of supervision contributed to the escalation of the situation before staff could intervene. Additional altercations occurred when residents with known wandering and aggressive behaviors entered each other's rooms, leading to further physical confrontations. In several cases, staff were not immediately present or were occupied with other duties, resulting in delayed intervention. The care plans for these residents identified their behavioral risks and the need for monitoring and redirection, but these interventions were not consistently implemented, allowing repeated incidents of physical abuse and neglect to occur among residents.