Failure to Protect Resident from Peer-to-Peer Physical Abuse
Penalty
Summary
The facility failed to ensure that residents were protected from abuse, as evidenced by an incident involving two residents with histories of mental illness and aggression. One resident, with diagnoses including schizophrenia, bipolar disorder, and major depressive disorder, and an intact cognitive status, was documented as having a history of physical aggression and poor impulse control. This resident became involved in a physical altercation with another resident who had severe cognitive impairment and a history of violent behavior. The altercation resulted in the second resident being pushed to the floor, sustaining a head laceration that required sutures and hospitalization. Multiple staff interviews confirmed that the first resident pushed the second resident, leading to the injury. The facility's records and staff statements indicate that there were prior documented incidents of agitation, aggression, and altercations involving the resident who initiated the push. Despite care plans noting the risk for aggression and abuse, the measures in place were insufficient to prevent the incident. The facility's abuse policy affirms the right of residents to be free from abuse and outlines procedures for prevention, but the occurrence of this event demonstrates a failure to protect residents from physical abuse by peers.