Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with quadriplegia and multiple comorbidities, including COPD, chronic pain syndrome, and anxiety disorder, was physically assaulted by another resident with a known history of verbal and physical aggression, dementia with behavioral disturbances, PTSD, and impulse disorder. The assault occurred when the aggressive resident approached the victim and, after a brief exchange, punched the resident in the face, head, and neck approximately 20 times. The victim sustained facial and scalp contusions, headache, and neck pain, requiring evaluation and treatment in the emergency room, including X-rays and a CAT scan, which showed no broken bones but confirmed contusions and the need for follow-up with a concussion specialist. Prior to the incident, the aggressive resident had documented behavioral issues, including previous episodes of verbal and physical aggression toward staff and other residents. The baseline care plan for this resident noted mental health and behavioral concerns but failed to specify the nature of these concerns or outline any interventions to address them. Progress notes and staff interviews confirmed that the resident's aggressive behaviors were ongoing and that staff and other residents felt unsafe around him. Despite these known risks, the care plan lacked adequate interventions to manage the resident's behaviors or to protect others in the facility. The facility's policy required measures to address the needs of residents and minimize the possibility of abuse, including addressing problematic resident behaviors. However, the lack of specific interventions and failure to implement effective behavioral management strategies for the aggressive resident resulted in a serious incident of resident-to-resident abuse. Staff accounts and documentation indicated that the aggressive resident's behaviors were not adequately managed, leading to actual harm to another resident.