Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in a skin tear injury. One resident, with a history of dementia, major depressive disorder, and traumatic brain injury, was identified as having potential for physical and verbal aggression. This resident was involved in an altercation with his roommate, who had moderate cognitive impairment and multiple psychiatric and medical diagnoses. The incident occurred when the aggressive resident struck his roommate on the left hand, causing a skin tear, as the latter was attempting to leave their shared room. Clinical documentation and staff interviews confirmed that the altercation resulted in a physical injury. The injured resident reported the incident to an LPN, who observed the wound and questioned both residents. Both provided conflicting accounts, with the aggressive resident referencing delusional beliefs and claiming the other resident had provoked him. The LPN and administrator both noted that the explanations given by the residents were inconsistent and, at times, nonsensical, but it was clear that a physical altercation had taken place, resulting in injury. The facility's investigation into the incident was ultimately unsubstantiated due to the lack of witnesses and conflicting statements from those involved. However, documentation revealed that the aggressive resident had a prior history of altercations and of taking belongings from others. Facility policies reviewed during the investigation emphasized the right of residents to be free from abuse and the facility's commitment to preventing such incidents, but the event demonstrated a failure to ensure this protection.