Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in an altercation that caused physical injuries. One resident, who was cognitively intact and had a history of hemiplegia, seizures, and psychiatric diagnoses, was involved in a physical altercation with another cognitively intact resident who had a history of multiple sclerosis, depression, and prior verbally abusive behavior. The incident occurred in their shared room, where one resident began yelling, making threats, and then physically assaulted the other using a metal cup, resulting in lacerations, scratches, bruising, and pain. The aggressor had a prior history of inappropriate behavior with other residents, including a previous altercation in May, after which interventions such as separation and psychiatric services were implemented. Staff interviews and documentation revealed that the altercation was not witnessed by staff, but immediate actions were taken after the incident was discovered, including separating the residents and assessing for injuries. The resident who was assaulted described being threatened, punched, scratched, and hit with a metal object, leading to visible injuries that required treatment. The aggressor was arrested by police following the incident. Prior to this event, the two residents had been paired as roommates due to a lack of previous issues between them, despite the aggressor's earlier behavioral concerns with other residents. Review of facility policies confirmed that residents have the right to be free from all forms of abuse, including physical and verbal abuse. However, the facility did not prevent the recurrence of resident-to-resident abuse, as evidenced by the prior incident involving the aggressor and the subsequent physical assault. The lack of effective preventive measures and monitoring contributed to the failure to protect residents from abuse by other residents.