Failure to Protect Residents from Abuse by Another Resident
Penalty
Summary
The facility failed to protect multiple residents from abuse, as evidenced by repeated incidents involving one resident who physically and verbally assaulted others. Four residents, all with varying levels of cognitive impairment, reported or were observed to have experienced physical aggression, verbal abuse, and threats from another resident. These incidents included hitting, spitting, yelling, and derogatory language directed at both residents and staff. In one instance, a resident was observed with dried blood and a scratch on their ear after being struck, while another resident reported being spit on and threatened. Documentation and interviews revealed that the aggressive resident had a history of altercations, including hitting another resident in the head, spitting in a resident's face, and pushing a walker against another resident's wheelchair. Staff were present during several of these events and attempted to intervene by separating residents and de-escalating situations. Despite these interventions, the aggressive behavior persisted, and multiple residents expressed fear and distress, with some stating they felt unsafe or threatened by the resident in question. The facility's policy prohibits abuse, neglect, and exploitation by anyone, including residents. However, the repeated nature of the incidents, the physical injuries observed, and the ongoing verbal abuse indicate that the facility did not ensure a safe environment free from abuse for all residents. The aggressive resident's actions were documented in incident reports, and staff and administrative interviews confirmed the ongoing challenges in managing the situation, but the abuse continued to affect multiple residents.