Failure to Prevent Resident-to-Resident Physical Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent resident-to-resident altercations, resulting in multiple incidents of physical abuse among residents. One resident with severe cognitive impairment and a history of psychotic disorder, schizophrenia, and anxiety disorder exhibited frequent aggressive and wandering behaviors, including entering other residents' rooms, taking their belongings, and physically and verbally assaulting both staff and peers. Despite care plan interventions such as one-on-one supervision, non-pharmacological interventions, and medication adjustments, the resident continued to display behaviors that led to altercations with other residents. Several documented incidents involved this resident physically assaulting other residents, including hitting, slapping, and sitting on another resident's leg, which resulted in the other resident kicking her. In other cases, the resident entered rooms uninvited, sat in occupied chairs or beds, and provoked agitation or physical responses from peers. Staff observations and interviews confirmed that the resident was difficult to redirect, medications were ineffective, and there was insufficient staffing to provide continuous supervision. Staff members expressed concerns about their ability to keep other residents safe from this resident's behaviors. The facility's own policies required protection of residents from abuse, including abuse by other residents. However, staff interviews revealed that the interventions in place were not sufficient to prevent repeated incidents of physical aggression. Staff reported that one-on-one supervision was not consistently provided, and the resident was able to move freely throughout the facility, leading to ongoing risk and actual harm to other residents. The documentation shows a pattern of inadequate supervision and failure to implement effective interventions to prevent resident-to-resident altercations.