Failure to Prevent Resident-to-Resident Physical Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect the rights of two residents to be free from physical abuse, resulting in two separate resident-to-resident altercations. In the first incident, a resident with a history of multiple altercations and diagnoses including paranoid schizophrenia, insomnia, major depressive disorder, and anxiety disorder, was under a physician's order for 24-hour one-on-one supervision due to aggressive behaviors. Despite this, the resident was left unsupervised in the lobby, where he made racial slurs and pushed another resident, causing that resident to fall from his wheelchair. Multiple staff interviews confirmed that the assigned one-on-one caregiver was not present at the time of the incident, and the resident admitted to pushing the other resident due to agitation triggered by loud noises and previous negative interactions. In the second incident, a resident with dementia and behavioral disturbances was struck in the face by another resident diagnosed with schizophrenia. The altercation occurred when the first resident's wheelchair became entangled with the other resident's wheelchair outside the activities room. The striking resident was also on one-on-one care due to combative behavior, but the altercation still occurred, resulting in the injured resident sustaining bleeding in the mouth. Interviews with staff and other residents indicated that both residents had a history of confusion and negative interactions, and this was the second altercation between them. The facility's own policy required adequate supervision and removal of residents who threatened or attacked others, as well as identification and monitoring of residents with a history of disruptive behaviors. However, in both cases, the required supervision was not maintained, and staff failed to prevent the altercations despite known risks and prior incidents. These failures resulted in physical harm to the residents involved.