Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by multiple incidents involving resident-to-resident altercations. In one instance, a resident with intact cognition and diagnoses including depression, schizophrenia, and bipolar disorder was physically struck on the arm by another resident who entered their room uninvited, resulting in a bruise. The incident was witnessed by staff and reported, with documentation indicating that the aggressor was moved and placed on one-to-one supervision. Another event involved a resident with hemiplegia and limited mobility who was confronted in their room by the same resident. Despite attempts to redirect the aggressor, a physical altercation ensued, resulting in a small tear on the resident's left arm. Staff and other residents reported hearing the commotion and observed the physical contact, with the aggressor swinging at the resident and making contact. A third incident occurred in the dining room, where a resident with moderate cognitive impairment and a history of physical and verbal aggression was struck on the head by the same resident during a verbal altercation. Staff intervened and separated the residents, and the affected resident was assessed for injuries, with no visible harm noted. These events demonstrate a pattern of resident-to-resident abuse that was not effectively prevented by the facility.