Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect multiple residents from abuse by other residents, as evidenced by several documented incidents involving physical altercations. Residents with significant psychiatric and cognitive impairments, including schizophrenia, bipolar disorder, dementia, and anxiety, were involved in repeated episodes of aggression. In one instance, a resident with paranoid schizophrenia and mild cognitive impairment was struck in the face by another resident during a supervised smoking session. Witnesses confirmed the altercation, and the aggressor had a documented history of agitation and aggressive behavior. Further incidents involved the same resident with a history of aggression, who slapped a roommate in the face and later struck another resident on the head following a verbal and physical confrontation. Staff interviews revealed that the aggressor was known for unpredictable and aggressive responses, particularly when provoked, and had a pattern of such behavior. Despite care plans noting the risk for harm to self or others and interventions to monitor and redirect behavior, these measures did not prevent the repeated occurrences of resident-to-resident abuse. Another incident involved a resident with severe cognitive impairment who punched a peer in the face after a dispute over rummaging through garbage. The victim exhibited visible redness on the face following the altercation. The facility's abuse policy prohibits abuse, neglect, and mistreatment by anyone, including other residents, but the documented events show that residents were not adequately protected from abuse by their peers. The report details that interventions were added to care plans after each incident, but does not describe any actions taken prior to the events that could have prevented the abuse.