Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents' right to be free from physical abuse by another resident, as evidenced by an altercation between two residents. On June 7, 2025, two residents with multiple psychiatric and medical diagnoses engaged in a physical confrontation near the facility's elevator. Both residents exchanged words, which escalated into physical contact, including hitting and kicking. Staff intervened and separated the residents, but both admitted to hitting each other during the incident. Documentation in the electronic medical records and behavior monitoring indicated that both residents were observed to be physically aggressive and expressed frustration or anger towards others on the day of the incident. Staff members, including a CNA, confirmed witnessing the altercation and intervening to stop it. The incident was reported to the abuse coordinator, and body checks were performed, revealing no visible injuries or complaints of pain from either resident. Both residents were cognitively intact but had histories of psychiatric disorders, including schizoaffective disorder, bipolar disorder, and psychosis. The altercation was reportedly triggered by a dispute over bathroom use. The facility's policy requires the prevention of abuse and the provision of a safe environment, but the incident demonstrated a failure to prevent resident-to-resident physical abuse as required.