Failure to Prevent Resident-to-Resident Abuse Resulting in Physical and Emotional Harm
Penalty
Summary
The facility failed to protect two residents from physical and verbal abuse by another resident, resulting in both physical harm and emotional distress. One resident with a history of paranoid schizophrenia, anxiety disorder, delusional disorder, and personality disorder engaged in aggressive behaviors, including attempting to punch another resident and making verbal threats. This included threatening to slit the throat of another resident, which led to that resident leaving the facility out of fear, embarrassment, and humiliation. The affected resident reported feeling unsafe, which disrupted their rehabilitation and stroke recovery. Another incident involved the same aggressive resident physically assaulting a cognitively impaired, nonverbal resident with a history of stroke, hemiplegia, apraxia, dysarthria, aphasia, and major depressive disorder. The aggressive resident was observed pushing the nonverbal resident in a wheelchair at high speed, then striking the resident multiple times on the head and shoulders. Witnesses reported that the nonverbal resident was visibly scared, in pain, and left with a scalp bruise and red marks, requiring hospital evaluation. Multiple staff and a housekeeper witnessed the incident, and the nonverbal resident's responsible party confirmed the emotional and physical impact of the assault. The facility's policy required the prevention of all forms of abuse, including resident-to-resident altercations, and mandated staff intervention and protection of residents from harm. Despite these policies, the facility did not prevent or adequately intervene in the repeated aggressive behaviors of the resident with a history of mental health disorders, resulting in physical and psychological harm to two vulnerable residents. Staff interviews and resident accounts confirmed that the incidents were reported to administration, but the affected residents and others in the facility expressed fear and distress due to the ongoing threat posed by the aggressive resident.