Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in two separate incidents involving a resident with a history of traumatic brain injury, bipolar disorder, and impulse control disorder. In the first incident, a moderately cognitively impaired resident physically assaulted a severely cognitively impaired resident by punching her in the face, causing her to fall backward and sustain a head injury. The injured resident was sent to the emergency room, where a CT scan revealed a small intraventricular hemorrhage and a scalp hematoma. The resident was evaluated by neurosurgery and returned to the facility after being deemed stable. In a separate incident, the same resident shoved another severely cognitively impaired resident, causing her to fall to the floor. Although this second resident was not injured, the event was witnessed by staff and confirmed through interviews and documentation. Both incidents occurred in common areas of the facility, with staff present in the vicinity. The resident responsible for the physical altercations had documented behavioral triggers related to personal space and belongings, and his care plan included interventions such as frequent observation and monitoring for behavioral triggers. However, these interventions did not prevent the physical abuse from occurring. The residents involved in these incidents had significant cognitive impairments and exhibited behaviors such as wandering and invading others' personal space, which contributed to the altercations. Staff interviews and video footage confirmed that the aggressive resident's behaviors were known and that staff had been educated on his triggers. Despite this, the facility did not effectively prevent the physical abuse, resulting in harm to at least one resident and the potential for fear, pain, and anxiety among those affected.