Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in a physical altercation between them. One resident, who was alert and oriented with a BIMS score indicating intact cognition, reported being struck multiple times in the head by another resident who was agitated and had a history of schizophrenia, anxiety disorder, and altered mental status. The incident occurred in a common area near the elevator, where the agitated resident made contact with the other resident's forehead, causing him to fall and sustain a large bruise on the forehead, a bump on the back of the head, and pain rated at 2 out of 10. Witnesses confirmed the injured resident was found on the floor and appeared hurt, while the aggressor was described as frequently agitated and difficult to redirect. Staff interviews and medical record reviews confirmed the sequence of events, with the injured resident stating he was repeatedly punched in the head and that the aggressor appeared to be holding a silver object, which he thought might be a knife. The aggressor's behavior was described as delusional and agitated, and he was not redirectable following the incident. The facility's abuse prevention policy states that residents have the right to be free from abuse, defined as the willful infliction of injury or pain, which was not upheld in this case.