Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to adequately supervise a resident with a known history of physical and verbal aggression, resulting in multiple incidents of resident-to-resident physical abuse. The resident in question had documented diagnoses including schizoaffective disorder, psychotic disorder with delusions, and severe cognitive impairment, and was noted in care plans and assessments to display daily physical and verbal behaviors directed toward others, as well as poor impulse control and a history of harm to others. Despite these documented risks, the resident was able to physically assault several other residents on multiple occasions. Specific incidents included the aggressive resident punching another resident in the left eye, causing a hematoma and bruising, and striking another resident in the right arm, resulting in pain lasting several days. Additional documented altercations involved the aggressive resident kicking, scratching, and hitting other residents, some of whom were severely cognitively impaired, non-verbal, or dependent on staff for activities of daily living. Staff and witness statements confirmed that these assaults occurred in common areas such as the dining room and that the aggressive resident's behavior was unpredictable and dangerous to both staff and other residents. The facility's own Abuse Prevention Program policy affirms the right of residents to be free from abuse and outlines the responsibility to prevent mistreatment and identify patterns of potential abuse. However, the repeated incidents involving the same aggressive resident demonstrate a failure to implement adequate supervision and interventions to protect vulnerable residents from physical abuse, as required by facility policy and regulatory standards.