Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect three residents from abuse when multiple incidents of physical altercations occurred between them. On two separate occasions, residents were observed slapping and hitting each other on the arms. In the first incident, two residents engaged in a physical altercation after an argument about seating, resulting in both slapping each other on the arms. In the second incident, two residents began hitting each other after one resident grabbed the other's belongings while sitting at the same table in the dining room. These altercations were witnessed by staff and a housekeeper, who intervened to separate the residents. As a result of these incidents, two residents sustained abrasions with bleeding, and one resident displayed bruising on her forearm. The involved residents had varying cognitive statuses, with one resident having severe memory impairment and others being cognitively intact. The facility's policy required the prevention and prohibition of all types of abuse, neglect, and exploitation, but these measures were not effectively implemented to prevent the physical altercations and resulting injuries.