Failure to Protect Residents from Repeated Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect multiple residents from abuse by another resident, resulting in repeated incidents of physical aggression. Specifically, one resident with a history of aggressive behaviors and multiple psychiatric and neurological diagnoses physically assaulted two other residents on three separate occasions. The incidents included hitting another resident on the shoulder and legs while verbally cursing, and striking a third resident on the thigh with his fists. These events were witnessed and documented by staff, and the aggressive resident's care plan had previously identified a risk for such behaviors, with interventions such as redirection and monitoring in place. The residents who were victims of the abuse had significant cognitive impairments and were unable to answer questions appropriately during interviews. Their care plans included interventions for monitoring and removing them from situations involving aggressive behavior, but these measures did not prevent the repeated incidents. Staff interviews confirmed that the aggressive resident was known for such behaviors, and attempts to transfer him to a behavioral hospital were unsuccessful due to his health status and guardian refusal. Documentation showed that staff were aware of the aggressive resident's behaviors and had updated care plans following incidents, but the interventions implemented were insufficient to prevent further abuse. The facility's policies on abuse and resident-to-resident aggression were in place, but the repeated nature of the incidents indicated a failure to ensure the safety and protection of residents from abuse and neglect as required.