Failure to Protect Residents from Abuse by Peers
Penalty
Summary
The facility failed to protect multiple residents from physical and verbal abuse by other residents, as evidenced by several documented incidents. One resident with schizophrenia and a history of behavioral symptoms, including delusions, hallucinations, and aggression primarily directed toward male residents, physically assaulted another resident by hitting him on the cheek and pulling his beard. This incident was witnessed by staff, and the victim, who had a history of being the target of altercations, reported feeling unsafe and described multiple threats and prior incidents involving the same aggressor. The aggressor had previously refused psychiatric services and medication, and her care plan included interventions such as redirection and frequent checks, but these measures did not prevent the abuse. Another resident reported being physically abused by the same aggressor, who threw water on his head. This resident, who was moderately cognitively impaired and had a history of behavioral issues, stated that staff were notified but did not take action. Additionally, a third resident received a threatening note from the aggressor, indicating intent to cause harm. This resident, who was cognitively intact but experienced anxiety and impaired coping, also reported the incident to staff but felt that no effective response was provided. The aggressor was known to leave threatening notes and enter male residents' rooms, causing fear among other residents. The report also documents a verbal altercation between two other residents, involving racial and discriminatory insults, which was witnessed by staff, residents, and surveyors. Staff interviews revealed that while some interventions such as redirection and frequent checks were attempted, staff did not consistently investigate or address all incidents of abuse, particularly those involving threatening notes. The DON acknowledged awareness of the threatening behavior but stated that not all incidents were investigated, as the notes were considered part of the aggressor's behavior and not deemed dangerous.