Failure to Prevent Resident-to-Resident Physical Abuse Due to Inadequate Supervision and Assessment
Penalty
Summary
The facility failed to protect residents from physical abuse perpetrated by another resident with a known history of severe mental illness and behavioral disturbances. One resident, who had diagnoses including Schizoaffective Disorder, Bipolar Disorder, Dementia with Behavioral Disturbance, and severely impaired cognition, was involved in two separate incidents where they physically struck other residents in the dining room. The first incident involved this resident approaching and hitting another resident on the right upper arm without provocation, and the second incident involved the same resident getting up from their chair and hitting a different resident on the left shoulder during a meal. Despite the resident's documented history of unpredictable and aggressive behaviors, including resistance to care, verbal aggression, and poor impulse control, the care plans did not include specific interventions or guidance for staff regarding the level of supervision required to prevent further abuse. Staff interviews confirmed that the resident's behaviors were unpredictable and that constant supervision would be necessary to prevent such incidents. However, after initial one-to-one supervision was discontinued following the first incident, no assessment was conducted to determine the ongoing level of supervision needed, and the resident was able to commit a second act of physical abuse. The facility's investigative files and staff interviews revealed that during both incidents, multiple staff members were present in the dining room, but most were unaware of the abusive acts until after they occurred. Only one staff member witnessed each event directly. The facility did not analyze or review the incidents in a manner that would determine the underlying causes or implement effective corrective actions to prevent recurrence, resulting in repeated abuse affecting multiple residents.