Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect the rights of multiple residents to be free from abuse by other residents, as evidenced by several documented incidents of resident-to-resident altercations resulting in physical harm and psychosocial distress. In one case, a resident with moderate cognitive impairment and a history of dementia was struck in the face with a door by another resident, resulting in an abrasion. The incident was witnessed by a staff member, who observed a verbal argument escalating to physical aggression. The perpetrator, who also had dementia and behavioral disturbances, was placed on increased supervision following the event. Another incident involved a resident with severe cognitive impairment who sustained a hematoma around the left eye after being slapped multiple times by another resident during an altercation in the dayroom. The aggressor, also severely cognitively impaired, had a care plan indicating a risk for verbal aggression. The altercation occurred while an LPN was present in the room but had their back turned at the time. Documentation indicated that the victim exhibited non-verbal signs of pain and distress following the incident. Additional altercations included a resident being pushed to the ground by another, resulting in a fracture, and a separate event where a resident was punched in the stomach after taking another resident's food. There was also an incident where two residents began arguing and physically hitting each other at the dinner table, requiring staff intervention. In each case, the facility's own policies defined such actions as abuse, and interviews with staff confirmed that these events met the definition of abuse and did not meet facility expectations. The report details that care plans for the involved residents included interventions for behavioral risks, but these measures were insufficient to prevent the abusive incidents.