Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect two residents from physical abuse by each other, resulting in both sustaining injuries. On the date of the incident, one resident with severe cognitive impairment and a history of bipolar disorder and alcohol-induced persisting dementia, who had recently experienced a gradual dose reduction and discontinuation of Zyprexa, exhibited increased agitation and aggressive behaviors. Despite documented behavioral changes and staff observations of escalating agitation, the resident was only restarted on Zyprexa two days prior to the altercation, which was not sufficient time for the medication to take effect. The second resident involved was cognitively intact but had diagnoses including alcohol-induced persisting dementia, anxiety disorder, and delusional disorder. This resident had a history of delusions and agitation toward others, as documented in the care plan. On the day of the incident, the first resident entered the dining room, displayed agitated behavior, and attempted to strike the second resident. In response, the second resident physically engaged with the first, resulting in both falling to the ground. The second resident sustained a left humerus fracture requiring medical intervention, while the first resident suffered bruising and an abrasion. Staff were not present in the dining room at the time of the altercation, and the incident was only discovered after a nurse heard noise and investigated. Prior to the event, there were multiple documented instances of the first resident's increased agitation and behavioral disturbances, including throwing furniture and being difficult to redirect. Despite these warning signs, there was no evidence of increased supervision or intervention to prevent resident-to-resident altercations, and both residents had no prior history of physical altercations with each other.