Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent and protect a resident from physical abuse when one resident threw a shoe at another, striking him in the back of the head. The incident occurred after a verbal disagreement in which one resident accused the other of stealing food, leading to the physical act. Both residents involved had documented cognitive or behavioral diagnoses, with one having moderate cognitive impairment and the other being cognitively intact. Interviews with the residents confirmed the incident, with the resident who was struck reporting the event to staff, who then separated the two individuals. Staff interviews indicated that neither resident had a prior history of aggressive behavior or conflict, and the incident was not witnessed by staff on duty at the time. The facility's policy on abuse and neglect requires an environment free from abuse and mandates thorough investigation of allegations. Despite care plans in place for behavioral monitoring, the event occurred without prior warning or intervention, resulting in a failure to prevent the physical abuse.