Failure to Protect Residents from Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical and mental abuse by another resident, resulting in multiple incidents involving three residents. One resident with a history of autism, schizophrenia, and aggressive behaviors, including throwing items, scratching, and hitting, was admitted to the facility and required supervision for safety. Despite documented needs for 1:1 supervision, this intervention was inconsistently implemented, particularly during the night shift, after it was determined the resident was usually sleeping. This lapse in supervision allowed the resident to enter other residents' rooms and common areas, leading to physical altercations and emotional distress among other residents. Several incidents were reported where the aggressive resident physically attacked others. One resident was scratched under the eye while sleeping, another reported being choked and was left emotionally distressed, and a third sustained scratches during an incident in the therapy gym. Staff interviews confirmed that the aggressive resident's behaviors were unprovoked and unpredictable, and that supervision was not consistently maintained as required by the care plan. In some cases, staff intervened after the incidents had already occurred, and residents expressed fear and anxiety following these events. The facility's investigation into these incidents did not substantiate the allegations of abuse, often attributing the aggressive resident's actions to his medical condition rather than willful intent. However, the facility's own abuse prevention policy defines abuse as the willful infliction of injury or mental anguish, regardless of the individual's mental or physical condition, and requires deliberate action rather than intent to harm. The facility did not consistently investigate or follow up with affected residents, and failed to maintain required supervision, directly leading to repeated resident-to-resident abuse and emotional harm.