Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with a history of mental illness and intact cognition was subjected to physical abuse by another resident while waiting in line. The incident involved one resident throwing coffee on and striking the other, as confirmed by video evidence, multiple staff witness statements, and the aggressor's own admission. The abused resident reported being hit in the mouth and having coffee thrown on her, and her care plan identified her as being at risk for abuse due to her mental health diagnosis. The facility's incident report and risk management documentation corroborated the occurrence of physical abuse. Despite the facility's policy to maintain a safe and secure environment free from abuse, the event occurred in a common area with staff present. Staff and administrative interviews acknowledged that the actions were willful and deliberate, and that the facility failed to provide a safe environment for the resident. The facility's abuse policy defines abuse as the willful infliction of injury or harm, and the incident met this definition according to both the administrator and the assistant director of nursing.