Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect multiple residents from physical abuse by other residents, resulting in several altercations. In one incident, a male resident with severe cognitive impairment and a history of physical and verbal behaviors was involved in a physical altercation with another male resident, also with severely impaired cognition and a history of aggression. The altercation occurred when one resident attempted to assist the other, leading to both residents striking each other. Staff attempted to redirect and separate the residents, but the altercation still occurred, and both residents were assessed afterward. Another incident involved two female residents, both with dementia and significant cognitive impairment. One resident, who had a history of aggressive behaviors and delusions, initiated a physical altercation in the hallway by grabbing and hitting another resident after a verbal exchange. The second resident sustained a superficial abrasion and complained of elbow pain. Staff responded by separating the residents and assessing for injuries. Both residents had documented behavioral issues and required supervision and monitoring, but the altercation still took place. In both cases, the residents involved had known behavioral and cognitive challenges, including histories of aggression, delusions, and difficulty with redirection. Care plans for these residents included interventions such as monitoring for danger to self or others, analyzing triggers, and providing cues to alleviate anxiety. Despite these interventions, the facility did not prevent the physical altercations, and residents were not adequately protected from abuse by other residents.