Failure to Protect Residents from Physical Abuse by Other Residents
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in multiple resident-to-resident altercations that caused significant harm. One incident involved a resident with moderate cognitive impairment and a history of behavioral disturbances punching another resident in the face twice, breaking the victim's jaw. Witness statements and medical records confirmed that the altercation was witnessed by staff, and the injured resident reported severe facial pain and was subsequently transferred to the hospital for evaluation and treatment. The facility's documentation submitted to the State Agency did not accurately reflect the severity of the incident, as more detailed accounts in witness statements and the electronic medical record described greater injury and aggression than initially reported. Another incident involved the same resident who sustained the jaw fracture later pushing a third resident to the floor, then kicking and attempting to run over the resident with a wheelchair. Witness statements from nursing staff described observing the aggressor kicking the fallen resident and running into her with the wheelchair. The clinical record for the aggressor documented a history of combative and aggressive behaviors toward both residents and staff, including entering other residents' rooms, rummaging through belongings, and being verbally and physically aggressive. Despite this documented pattern, the facility's reporting to the State Agency again did not fully capture the extent of the altercation as described in internal records and staff statements. Interviews with staff revealed that some incidents of resident-to-resident aggression were not reported to facility leadership or the State Agency, and that staff had not received additional training on abuse reporting expectations. Staff also reported overhearing inappropriate comments from other staff members regarding the incidents, and there was acknowledgment of discrepancies between witness statements and the facility's official investigation documentation. The facility's abuse and neglect policy defined physical abuse and willful actions but did not appear to be consistently followed in practice, as evidenced by the incomplete and inaccurate reporting of serious resident-to-resident abuse events.