Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in two separate incidents involving resident-to-resident altercations. In the first incident, a resident with severe cognitive impairment and multiple medical conditions, including dementia and a recent femur fracture, wandered into another resident's room. The second resident, also severely cognitively impaired with a history of behavioral symptoms and a preference for personal space, pushed the first resident, causing a fall and a subsequent femur fracture. Staff interviews and care plan reviews indicated that the resident who pushed had known behavioral triggers related to personal space, and interventions such as a stop sign on the door and staff redirection were in place, but these measures were not sufficient to prevent the incident. In the second incident, a resident with moderate cognitive impairment and schizoaffective disorder was sitting on a couch when another resident, who was cognitively intact but had a history of hallucinations and behavioral outbursts, approached and struck him in the face. The altercation was witnessed by another resident and confirmed by video footage. The victim sustained a small bruise near the eye but did not retaliate or express fear. Staff and resident interviews revealed that the assailant had a history of unpredictable aggression, often without clear triggers, and had been involved in several previous altercations with different residents. Both incidents demonstrate that the facility did not adequately prevent physical abuse between residents, despite having policies and care plans addressing behavioral risks. Staff were aware of the behavioral histories and triggers of the residents involved, and interventions such as increased monitoring and environmental cues were in place, but these were not effective in preventing the physical altercations that resulted in injury and distress among the residents.