Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from resident-to-resident physical abuse, specifically involving a resident with severe dementia and behavioral disturbances. This resident, who was documented as severely cognitively impaired and exhibiting physical and verbal aggression, was involved in multiple incidents where she physically assaulted other residents. These incidents included kicking another resident on the shin resulting in a hematoma, hitting a resident on the shoulder during a group activity, slapping another resident on the arm multiple times, and kicking a resident who was found in her bed. All of these incidents were witnessed by staff or other residents and were documented in incident reports. Despite the resident's known history of aggression and a care plan that called for one-on-one supervision during episodes of aggression, the facility did not prevent repeated physical abuse of other cognitively impaired residents. The facility's own policy states that residents have the right to be free from abuse, including resident-to-resident abuse, yet the aggressive resident was able to continue these behaviors. The administrator confirmed the pattern of physical aggression and acknowledged these incidents as examples of physical abuse.