Failure to Prevent Resident-to-Resident Abuse Due to Inadequate Monitoring
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving two residents who were assaulted by another resident with a known history of aggressive and assaultive behavior. One resident, who had diagnoses including schizoaffective disorder and moderate cognitive impairment, exhibited escalating agitation and aggression, including punching doors and displaying assaultive behavior toward both staff and peers. Despite these behaviors, the resident was removed from one-to-one (1:1) monitoring after a period of time, based on the discontinuation of suicidal ideation, even though the resident continued to display assaultive tendencies. Following the removal from 1:1 monitoring, the resident physically assaulted two other residents on separate occasions. In the first incident, the resident struck another resident on the head with a food tray while that resident was eating breakfast. In the second incident, the same resident hit another resident on the head and pulled their hair during a smoke break on the facility's patio. Both incidents were unprovoked, and staff interviews confirmed that the resident had a pattern of aggressive outbursts and that 1:1 monitoring was intended to prevent such harm. The affected residents experienced pain and psychological distress as a result of these assaults. One resident reported feeling unsafe and afraid of further assaults, expressing ongoing discomfort and fear for their safety. Documentation and interviews indicated that the facility's failure to maintain appropriate supervision and monitoring, as outlined in their own policies and follow-up investigation report, directly led to these incidents of abuse and the resulting harm to the residents.