Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Serious Injury
Penalty
Summary
A resident's right to be free from physical abuse was not protected when another resident became physically aggressive, resulting in a serious injury. The incident occurred late at night when one resident entered another's room, used racial slurs, and physically assaulted him by punching him in the face and choking him. The altercation was only interrupted when a CNA, alerted by the sounds of the struggle, entered the room. The victim sustained a right medial orbital wall blowout fracture, as confirmed by hospital CT scan records. Prior to the physical altercation, the aggressor had been sending threatening and racially charged text messages to the victim, demanding information unrelated to the victim. Despite the known behavioral issues and the need for staff to monitor the aggressor closely, the incident escalated to physical violence. Staff interviews indicate that the aggressor was observed heading toward the victim's hallway, and staff were aware of the need to keep an eye on him, but the assault still occurred. Both residents involved had multiple medical and psychiatric diagnoses, with the aggressor having a history of anxiety disorder and PTSD, and the victim having schizophrenia, bipolar disorder, and substance abuse issues. The facility's abuse prevention policy states that residents have the right to be free from abuse, including physical abuse, but the events leading up to and during the incident demonstrate a failure to prevent resident-to-resident abuse, resulting in significant harm.