Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect two residents from abuse by another resident, resulting in physical harm and emotional distress. On one occasion, a resident with a history of noncompliance and mental/emotional illness pushed another resident out of a wheelchair, causing a laceration to the forehead. The incident was witnessed by staff, and the injured resident reported being shoved multiple times before falling and sustaining the injury. The aggressor admitted to the action, and the injured resident was relocated for safety. A few days later, the same resident became agitated, shoved a staff member who was assigned to provide one-on-one supervision, and then physically assaulted another resident in a common area. The second assaulted resident reported being punched in the arm and having their arm pulled, resulting in immediate and residual pain, as well as feelings of being attacked. Staff interviews confirmed that the aggressor was difficult to redirect and had exhibited escalating aggressive behavior over a two-week period, including verbal abuse toward other residents. Care plans for the involved residents indicated known behavioral and mental health issues, including histories of impulsive behavior, trauma, and mood disorders. Despite these documented risks, the facility did not prevent the resident-to-resident altercations that resulted in physical injuries and emotional harm. Staff were aware of the aggressor's potential for abusive behavior and had implemented one-on-one supervision, but this intervention did not prevent further incidents.