Failure to Prevent Resident-to-Resident Abuse Following Behavioral Escalation
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in a physical altercation between them. One resident, who is cognitively intact and has a history of schizoaffective disorder and bipolar disorder, admitted to taking personal belongings (Kool-Aid) from his roommate, who has moderate cognitive impairment and diagnoses of bipolar disorder and schizophrenia. The incident escalated when the cognitively impaired resident discovered his belongings had been taken, leading to a verbal and physical confrontation in which he punched the other resident in the stomach. The assaulted resident was subsequently sent to the hospital for evaluation, though no injuries were found. Prior to the incident, there were documented behavioral concerns for both residents. The resident who took the Kool-Aid had a care plan noting a risk for abuse and a history of inappropriate sexual behaviors, including making advances and entering other residents' rooms without permission. The roommate, who rarely left his room, reported ongoing issues with his roommate going through his belongings and making him uncomfortable by blowing kisses and placing a profile picture on his television. Despite these documented risks and behaviors, the facility did not prevent the altercation from occurring. The facility's abuse policy affirms residents' rights to be free from abuse and outlines that residents who allegedly abuse others should be immediately evaluated for appropriate therapy, care approaches, and placement. However, the events indicate that the facility did not adequately protect the residents from abuse or prevent the escalation of known behavioral issues, resulting in a physical altercation and the need for medical evaluation and police involvement.