Failure to Prevent and Address Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically resident-to-resident altercations, for three of five sampled residents. On 9/11/25, an altercation occurred between two residents involving verbal and physical aggression, including yelling, swearing, threats, and physical contact with mobility devices. The care plan for the resident identified as the initial aggressor did not include goals, triggers, or interventions related to aggressive behavior, and the incident was neither investigated nor reported to the State Agency as required by facility policy. Following this, on 9/13/25, the same resident entered another resident's room and physically assaulted them by slapping them multiple times. This second incident was investigated and reported, but the lack of intervention after the first altercation was noted as a missed opportunity to prevent further abuse. Interviews with facility staff, including the Unit Manager and Director of Nursing, revealed that they were unaware of the initial incident and acknowledged that it should have been investigated and addressed per policy. The residents involved had significant medical and cognitive conditions, including dementia with behavioral disturbance, cerebral infarction, and other chronic illnesses. Both the Unit Manager and Director of Nursing confirmed that the care plan for the aggressive resident should have been updated immediately after the first incident, and that the failure to do so left other residents unprotected from further aggression.