Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from verbal, mental (emotional), and physical abuse, as evidenced by incidents involving two residents. One resident, with a history of chronic obstructive pulmonary disease, atrial fibrillation, and diabetes, was described as having intact cognition and independence in daily activities. This resident was subjected to physical abuse when another resident, who also had intact cognition and a history of intervertebral disc degeneration, osteoarthritis, COPD, and diabetes, became physically aggressive. The aggressive resident stood up from a wheelchair, grabbed the first resident by the neck, choked, and punched them in the stomach. This altercation was witnessed by staff, who observed the physical contact and subsequent injury, including a scratch on the neck that required treatment. The report also documents ongoing verbal and emotional abuse between the two residents. The aggressive resident reported being repeatedly called derogatory names, such as "crack head," by the other resident over the course of a year, despite having asked for the behavior to stop and social services having intervened multiple times. Staff interviews confirmed that the resident who was physically assaulted had a pattern of teasing and using inappropriate language toward other residents, which was recognized as verbal abuse by both nursing and administrative staff. The facility's policy defined such behavior as abuse, including the use of disparaging or derogatory language. Despite documented behavioral issues and ongoing conflict between the two residents, the facility did not prevent the escalation to physical violence or adequately protect the residents from continued verbal and emotional abuse. Staff were aware of the problematic interactions, and interventions by social services had occurred, but the abusive behaviors persisted, culminating in a physical altercation that resulted in injury. The facility's failure to prevent these incidents constituted a deficiency in protecting residents' rights to be free from all forms of abuse.