Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in two residents experiencing pain, injury, and fear for their safety. One resident with severe cognitive impairment, Alzheimer's disease, and a history of behavioral disturbances was known to wander unsupervised and had prior incidents of aggression. This resident entered another resident's room, touched personal belongings, ate food, and became physically aggressive when confronted, swinging her arms and making physical contact that resulted in redness on the other resident's neck. The affected resident, who had intact cognition and a history of depression and chronic pain, reported feeling abused and expressed fear, leading him to avoid activities and remain in his room for safety. In a separate incident, the same resident with cognitive impairment approached another resident in the dining room, touched her belongings, and slapped her on the back of the head when she tried to intervene. The resident who was struck, who had moderate cognitive impairment, hemiplegia, and mental health diagnoses, complained of pain and expressed feeling unsafe and wanting to leave the facility. Witnesses, including another resident and staff, confirmed the aggressive behavior and noted that the resident responsible for the incidents was not monitored at all times, despite being on special monitoring due to her known wandering and aggression. Staff interviews revealed that the facility did not provide sufficient supervision to prevent the aggressive resident from entering other residents' rooms or causing harm. Multiple staff members and residents reported that the aggressive resident frequently wandered unsupervised and that staff were often too busy to monitor her continuously. The facility's policy stated that residents have the right to be free from abuse, including abuse by other residents, but the observed incidents and staff accounts demonstrated a failure to uphold this standard.