Failure to Prevent Resident-to-Resident Physical Abuse Due to Lack of Interventions
Penalty
Summary
The facility failed to protect two residents from physical abuse when a physical altercation occurred between them. One resident, who had a history of not tolerating noise and demonstrated roommate incompatibility, became involved in a confrontation with their roommate over the use of a television. The altercation escalated when one resident turned off the other's TV, leading to a series of physical exchanges, including hitting with a closed fist and striking with a wheelchair footrest. Both residents sustained injuries, including scratches, cuts, and reported pain, requiring first aid and further medical evaluation. The facility did not follow its own policy and procedure regarding abuse prevention, which mandates protecting residents from abuse by anyone, including other residents. There was a lack of interventions in place to prevent the altercation, despite documented behavioral triggers and incompatibility between the two residents. Staff interviews confirmed that the altercation was avoidable and that the facility should have implemented measures to ensure a safe environment, particularly given the known behavioral history of one of the residents. Record reviews revealed that one resident had moderate cognitive impairment and required assistance with daily activities, while the other had severe cognitive impairment with psychotic disturbances. The care plan for the resident with behavioral triggers did not address these triggers or provide specific interventions to prevent outbursts. Staff acknowledged that a care plan should have been developed to address these issues, and the absence of such planning contributed to the occurrence of the physical abuse.