Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A resident with vascular dementia and schizophrenia, who was severely cognitively impaired and dependent for wheelchair mobility, was physically abused by another resident diagnosed with dementia, paranoid schizophrenia, and schizoaffective disorder. The incident occurred when the second resident, who had a history of physical aggression and prior altercations, approached the first resident in the hallway and slapped the left side of their face. This act was witnessed by a non-staff member and a nursing assistant, with the latter observing the aggressor slap the victim a second time. The victim was found with facial redness as a result of the incident. Prior to the event, the aggressive resident had refused medications and was on a waitlist for in-patient psychiatric evaluation, with ongoing psychiatric follow-up and 15-minute checks in place. Despite a documented history of similar altercations, the facility failed to prevent the physical abuse, as required by their abuse policy, which prohibits residents from being subjected to abuse by anyone, including other residents. The facility's documentation and staff interviews confirmed the physical contact and the resident's history of aggression, but did not consider the contact willful.