Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with a history of schizophrenia, schizoaffective disorder, and audio hallucinations physically assaulted another resident by approaching from behind and placing his arm around the other resident's neck in a chokehold during a group activity in the dining room. The aggressor stated, through a translator, that he was compelled by auditory hallucinations, specifically that God told him to choke the other resident. The incident was witnessed by a staff member who intervened and separated the two residents. The aggressor was calm after the incident and did not display agitation. The assaulted resident, who has diagnoses including schizophrenia, chronic obstructive pulmonary disease, and hypertension, reported being surprised by the attack and did not recall any provocation or warning. He denied pain or injury following the incident, and a licensed practical nurse confirmed there were no visible signs of harm. The aggressor had a documented history of behavioral disturbances, hallucinations, and a felony history for aggravated stalking, and was known to be at risk for abuse/neglect according to his care plan. The facility's abuse policy and residents' rights documents state that all residents must be protected from abuse, neglect, and harm. Despite these policies, the incident occurred in a supervised setting with only one staff member present, who was required to physically intervene. The aggressor was subsequently referred for psychiatric evaluation due to his aggressive and psychotic behavior, but the event demonstrated a failure to protect a resident from physical abuse by another resident.