Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident. The incident began when one resident entered the shared room of two others, leading to an argument in which food was thrown. The situation escalated when the first resident, after discovering his property had been damaged, returned and threw a wheelchair armrest at one of the residents, which then struck both individuals. This altercation was not witnessed by staff, but staff responded after hearing the commotion and separated the residents. No injuries were reported, but the event involved physical aggression and property damage. The residents involved had documented histories of behavioral and mental health issues, including anxiety, depression, and, in one case, schizoaffective disorder. Assessments indicated that at least one resident had a history of verbal behavioral symptoms directed toward others, and care plans noted the potential for physical aggression related to anger and poor impulse control. Despite these known risks, the altercation occurred without staff intervention until after the physical abuse had taken place. Staff interviews confirmed that the residents had a history of volatile interactions, described as similar to a sibling rivalry, and that staff were aware of the need to monitor their interactions. However, the incident was not prevented, and staff only intervened after the situation had escalated to physical abuse. The facility's policy required the protection of residents from abuse by anyone, including other residents, but this policy was not effectively implemented in this instance, resulting in a failure to prevent physical abuse.