Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse involving two residents, one of whom was cognitively intact with a history of schizoaffective disorder and cerebral palsy, and the other moderately cognitively impaired with dementia and multiple comorbidities. The incident occurred in the basement dining room, where one resident approached the other and struck him in the face, reportedly in response to being called an inappropriate name. Multiple staff and resident witness statements confirmed that the aggressor hit the other resident, at times using a can of soda, and that the altercation escalated to physical violence before staff intervened and separated the individuals. The injured resident was observed with a superficial scratch under his eye, which was treated with basic first aid and healed without complications. Witness accounts varied regarding the precipitating factors, with some indicating verbal provocation and others stating the attack was unprovoked. The aggressor was subsequently sent to a hospital for psychiatric evaluation due to increased agitation and aggressive behavior, and a petition for involuntary admission was completed, citing the individual's risk of harm to self or others if not treated on an inpatient basis. Documentation and interviews revealed that staff were not present in the immediate area at the time of the incident and were alerted by a housekeeper who witnessed the altercation. The facility's abuse policy prohibits all forms of abuse and affirms residents' rights to be free from such mistreatment. Despite this policy, the facility did not prevent the physical abuse that occurred between the two residents.