Failure to Protect Resident from Repeated Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a cognitively impaired resident from physical abuse by another resident with a known history of aggression. Despite multiple documented incidents where the aggressive resident engaged in physical altercations—including slapping, grabbing, pushing, and throwing objects at both residents and staff—no effective interventions or safety measures were implemented to prevent further abuse. On one occasion, the aggressive resident shoved the other resident into a bird aviary, resulting in broken glass and a scratch on the victim's back. The aggressive resident had a documented history of behavioral issues, including physical and verbal aggression, wandering, and difficulty with redirection. Medical records indicated the use of psychotropic medications and as-needed interventions for aggression and anxiety. Despite repeated incidents of aggression towards both residents and staff, the care plan for the aggressive resident did not include new or updated interventions after each event. Staff and the DON acknowledged that no increased monitoring or checks were put in place following these incidents, and the aggressive resident continued to have unsupervised access to other residents. Interviews with staff, the DON, the primary care provider, and the resident's guardian confirmed awareness of the ongoing behavioral issues and the lack of adequate safety measures. The primary care provider and guardian both expressed concerns about the appropriateness of the placement and the absence of interventions to protect other residents after each incident. Observations during the survey showed the two residents together without staff intervention or increased supervision, even after the most recent incident of physical abuse.