Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent two residents from physically abusing one another. One resident, a female with diagnoses including diabetes, COPD, schizoaffective disorder, and heart failure, reported being verbally and physically attacked by her roommate, who has diagnoses including COPD, dementia, and mood disturbance. The incident began with a verbal disagreement that escalated to physical violence, with one resident stating she was hit in the head and face by her roommate. The other resident confirmed that both parties hit each other during the altercation, which occurred in their shared room without staff present. Staff interviews revealed that although staff were aware of ongoing verbal disagreements between the two residents and intervened at least once to separate them, they did not witness the physical altercation. Staff responses included calling a nurse to the scene and sending one resident out of the facility, but no staff member reported seeing or being informed of the physical abuse at the time. The facility's abuse policy defines physical abuse as the infliction of injury by non-accidental means, including hitting, slapping, or kicking, which was not prevented in this case.