Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect multiple residents from abuse, resulting in several incidents of physical aggression between residents. In one case, a resident with hemiplegia and a history of verbal aggression struck another resident in the back of the head after being called a derogatory name. Both residents involved had cognitive impairments and behavioral histories, and the altercation was preceded by verbal exchanges. Staff and administration were aware of prior verbal altercations but did not implement interventions to prevent escalation to physical abuse. Another incident involved two residents in the dining room, where one resident with dementia and a history of psychosocial issues physically assaulted another resident, causing visible injuries including a laceration and bruising. The altercation was triggered by a dispute at the lunch table, with conflicting accounts from residents and staff about the sequence of events. Staff were not present in the dining room at the time of the incident, and the response to the altercation was delayed, resulting in one resident being struck multiple times before staff intervened. A third incident occurred when a resident with a history of aggressive behavior poured hot sauce on the face of another resident with severe cognitive impairment. The event followed a pattern of playful interactions that escalated into aggression, with both residents initially engaging in mutual teasing. Staff observed the aftermath and intervened to separate the residents and provide care. In all cases, the facility's failure to adequately supervise residents, recognize escalating behaviors, and implement preventive interventions contributed to the occurrence of abuse.