Failure to Prevent Resident-to-Resident Abuse Due to Lack of Supervision
Penalty
Summary
The facility failed to prevent verbal and physical abuse between two residents on the behavioral health locked unit. On the evening of 12/26/25, two residents with significant psychiatric diagnoses, including paranoid schizophrenia, schizoaffective disorder, bipolar disorder, and major depression, engaged in a verbal and physical altercation. The incident occurred after one resident became upset about not receiving medication due to a facility internet outage, which delayed the medication pass. The two residents exchanged words, escalated to yelling, and then one resident struck the other in the upper arm. At the time of the incident, there were no staff members present on the locked behavioral unit. The Certified Medication Technician (CMT) assigned to the unit had left to print medication administration records necessary for the medication pass, as the internet was down. Multiple resident interviews confirmed that staff were not present during the altercation, and one resident had to bang on the locked doors to alert staff to the fight. Staff interviews corroborated that the unit was unsupervised during the event, and the administrator acknowledged that staff supervision was expected at all times on the unit. The facility's own Abuse and Neglect Policy states that residents have the right to be free from abuse and that the facility will actively protect residents from such incidents. The lack of staff supervision on the locked behavioral unit directly contributed to the occurrence of resident-to-resident abuse, as there was no immediate intervention or oversight to prevent or de-escalate the situation.