Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect the rights of two residents to be free from abuse by other residents. In the first incident, a resident with severe cognitive impairment, schizophrenia, and a history of physical behaviors physically assaulted another resident and a CNA. The resident was observed wandering the halls, attempting to enter other residents' rooms, and ultimately struck another resident on the head, resulting in bleeding from the lower gums. Staff interviews confirmed that the resident was redirected multiple times but was able to physically assault both a peer and a staff member before being separated. In a separate incident, another resident with severe cognitive impairment and a history of physical and verbal aggression struck a peer on the nose following a collision involving a wheelchair. The aggressor admitted to hitting the other resident in response to the perceived provocation. Staff present at the time separated the residents and assessed them for injuries, with no acute injuries noted. Both residents involved in this altercation had documented behavioral concerns and histories of aggression related to their cognitive decline. In both cases, the facility's documentation, staff interviews, and clinical records indicate that residents with known behavioral risks were able to physically harm other residents. The incidents were verified by facility-reported incident forms and involved residents with significant cognitive and behavioral challenges, including dementia, schizophrenia, and a history of aggression.