Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in a physical altercation between them. One resident, a female with moderate cognitive impairment and multiple psychiatric diagnoses, had a documented history of aggressive and inappropriate behavior towards other residents, including physical aggression and use of racial slurs. Her care plan noted risks for bleeding and bruising due to aspirin use, and previous incidents had required staff intervention to separate residents and assess for injuries. The other resident, a male also with moderate cognitive impairment and psychiatric diagnoses, similarly had a history of socially inappropriate and provocative behavior, including ramming his wheelchair into others. On the day of the incident, both residents encountered each other near the smoking area, exchanged words, and the female resident provoked the male resident by grabbing his pants and using racial slurs. Multiple staff members observed escalating verbal aggression, but the residents were not effectively separated or de-escalated before the situation became physical. The altercation resulted in the female resident sustaining a laceration above her eye, which required hospital treatment. Interviews with staff and residents revealed that the altercation involved both verbal and physical aggression, with the female resident striking the male resident and the male resident using his cane in self-defense, leading to the injury. The facility's failure to prevent the altercation, despite both residents' known behavioral risks and prior incidents, constituted a deficiency in ensuring residents' right to be free from abuse. Staff interviews indicated that while some attempts were made to separate and redirect the residents, these measures were not sufficient to prevent the physical confrontation and resulting injury.