Failure to Protect Resident from Physical Abuse Resulting in Injury and Decline
Penalty
Summary
The facility failed to protect a resident from physical abuse, resulting in significant harm. One resident with a history of violent behavior, as noted in an email from the prior interim DNS, was not care planned for these behaviors, and no interventions were documented to address the risk. This resident physically assaulted another resident in a hallway, pushing the individual to the ground and punching them, which was witnessed by staff and required immediate intervention to separate the two. The assaulted resident, who had a history of multiple spinal fractures and mild cognitive impairment, sustained a lumbar spinal fracture, rib pain, and difficulty breathing as a result of the incident. Following the assault, the resident experienced severe and prolonged pain, as documented in pain records and medication administration records, requiring increased pharmaceutical interventions including acetaminophen, ibuprofen, oxycodone, fentanyl, and morphine. The resident's condition deteriorated, becoming bedridden, refusing care and medications, and exhibiting increased confusion and agitation. Multiple staff interviews confirmed that the resident was previously independent and ambulatory but became bedridden and in significant pain after the incident. Staff also confirmed that the incident was considered assault and abuse. The facility's failure to address the known violent behaviors of the aggressor resident and to implement appropriate care planning and interventions directly led to the physical abuse and subsequent decline of the victim resident.