Failure to Prevent Resident-to-Resident Physical Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect three severely cognitively impaired residents from repeated physical abuse by another resident with a known history of aggressive and violent behaviors. The resident responsible for the abuse had diagnoses including Huntington's disease and demonstrated ongoing physical and verbal aggression, wandering, and impulsive behaviors since admission. Despite these documented behaviors, the facility's interventions and supervision were inconsistent and insufficient to prevent further incidents. Multiple incidents occurred in which the aggressive resident physically assaulted other residents, including hitting, hair-pulling, and pushing. These incidents were witnessed by staff and documented in clinical and investigative records. After each event, interventions such as 15-minute checks and 1:1 supervision were ordered; however, there was no evidence that these interventions were consistently implemented. Documentation revealed significant gaps in monitoring records, and staff failed to maintain required supervision, even after repeated episodes of abuse. The facility's failure to implement and maintain adequate supervision and monitoring measures directly resulted in repeated physical abuse of vulnerable residents. The lack of consistent follow-through on ordered interventions, as well as the absence of proper documentation and staff adherence to supervision protocols, allowed the aggressive resident to continue perpetrating abuse against other residents. Facility leadership confirmed these failures during interviews, acknowledging that the measures in place were not sufficient to prevent the abuse.