Failure to Prevent Resident-to-Resident Abuse Resulting in Physical Harm
Penalty
Summary
The facility failed to protect two residents from physical and emotional abuse by other residents. In the first incident, a resident with severe cognitive impairment and a history of aggressive behavior struck another resident, who was wheelchair-bound and totally dependent on staff, with a pillow multiple times. This occurred after the aggressor believed the other resident was interfering with his belongings. Staff, including a licensed nurse and a CNA, witnessed the incident and confirmed that the resident being struck attempted to protect himself. The administrator substantiated the occurrence as resident-to-resident abuse. In the second incident, a resident with no cognitive impairment but a history of behavioral issues and fabricating stories engaged in a physical altercation with her roommate, who was also physically dependent due to medical conditions. The altercation began after a dispute over personal items and the use of a television. During the incident, a full bottle of nutritional supplement was thrown, resulting in a bruise to the dependent resident's lower lip. Both residents provided conflicting accounts, but staff observations and interviews indicated a pattern of negative interactions and previous behavioral concerns. The administrator substantiated this event as resident-to-resident abuse as well. The facility's own policies define abuse as the willful infliction of injury and require the protection of residents from all forms of abuse and neglect. Despite documented behavioral risks and care plans addressing these issues, the facility did not prevent these incidents, resulting in physical harm and emotional distress to the affected residents. The findings were based on interviews, record reviews, and direct observations by staff and surveyors.