Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident (R2) from abuse by another resident (R1), resulting in physical and psychosocial harm. R1 and R2, both with severe cognitive impairment, were roommates and had escalating verbal altercations over a period of several weeks. Documentation showed that R1 exhibited increasing agitation, aggression, and behavioral disturbances, including verbal and physical aggression toward staff and other residents. Despite repeated documentation of these behaviors and ongoing conflict between the two residents, the facility did not revise R1's care plan, reassess the risk of the roommate pairing, or implement additional interventions to prevent harm. Staff interviews and progress notes indicated that R1's behaviors became more difficult to redirect, and that both residents were involved in frequent verbal altercations. Staff reported that the behaviors had been ongoing and that interventions such as redirection were unsuccessful. The social worker was not notified of the escalating conflict, and no changes were made to the residents' room assignments or supervision levels prior to the incident. The facility also failed to obtain behavioral health services for R1, despite documentation of severe behavioral symptoms and cognitive impairment. The situation culminated in an unwitnessed physical altercation in which R2 was found on the floor with a head injury, and R1 was observed standing over him. R2 required transport to the hospital for evaluation and was diagnosed with a head injury, neck muscle strain, and a suspected wrist ligament injury. Interviews with staff and R2 confirmed that R1 had threatened and physically harmed R2, resulting in fear and ongoing psychosocial distress for R2. The facility's lack of timely intervention and failure to address the escalating conflict directly led to the incident of abuse.