Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse involving two cognitively intact residents with documented histories of behavioral issues, including verbal aggression and inappropriate interactions with peers and staff. One resident, who had diagnoses including metabolic encephalopathy and generalized anxiety disorder, was noted to have escalating behaviors such as demanding money, verbal abuse, and combative actions toward both staff and other residents. The other resident, with major depressive disorder and bipolar disorder, also had a history of verbal aggression and was identified as being at risk for abuse and neglect. On the day of the incident, the first resident was observed asking for money from peers and staff, becoming verbally abusive when refused. During a music activity in the dining room, the second resident confronted the first resident about their behavior. Video footage and multiple staff interviews confirmed that the second resident aggressively pushed and pulled the first resident's chair, after which the first resident swatted at the second resident, making contact with her breast. The second resident then retaliated by hitting and kicking the first resident. Staff present at the time reported difficulty in de-escalating the situation, and one aide had to leave the room to seek additional help, during which time the altercation occurred. The facility's investigation confirmed that an altercation took place, with both residents engaging in physical contact. The incident resulted in the second resident feeling unsafe in the facility. The facility's abuse prevention policy prohibits physical abuse, including hitting and controlling behavior, but the measures in place were insufficient to prevent this resident-to-resident altercation.