Failure to Prevent Resident-to-Resident Physical Abuse Due to Inadequate Behavioral Management
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when it did not address the escalating behaviors and medication noncompliance of another resident, resulting in a violent incident. One resident, with a history of dementia, schizophrenia, noncompliance with medical treatment, and traumatic brain injury, exhibited increasing aggression, including verbal outbursts, throwing objects, breaking equipment, and refusing psychotropic medications. Despite these behaviors and multiple staff observations of his unpredictability and aggression, the resident was placed in a shared room with another resident who also had a history of agitation, violent behavior, and psychiatric symptoms. Staff interviews and record reviews revealed that both residents had known behavioral issues, and several staff members expressed concerns that they should not have been placed together. The aggressive resident's refusal to take prescribed psychotropic medications was documented, and his behavior escalated from verbal to physical aggression, including breaking facility property and threatening others. Although staff recognized the risk, the interdisciplinary team did not address the issue during meetings, and no effective interventions were implemented to separate the residents or ensure appropriate monitoring. The situation culminated in a physical assault, where the aggressive resident repeatedly struck his roommate, causing multiple facial injuries that required hospital treatment. Documentation and interviews confirmed that the facility's failure to assess, plan, and intervene appropriately in response to the escalating behaviors and medication noncompliance directly led to the incident. The facility's own policy required ongoing assessment and care planning for residents with behaviors that might lead to conflict, but this was not followed, resulting in harm to a resident.