Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse, resulting in one resident sustaining swelling to the left side of the face near the eyebrow. The incident involved a resident with multiple complex medical diagnoses, including moderate cognitive impairment, who was physically assaulted by a roommate with a documented history of aggressive and violent behaviors. The aggressive resident had previously exhibited both verbal and physical aggression toward staff and other residents, including being sent to the hospital for psychiatric evaluation due to these behaviors. On the day of the incident, the aggressive resident was observed by staff charging toward the other resident, who was in bed eating lunch. The assaulted resident reported that the aggressor was slamming drawers, taking belongings, and then struck him on the left side of the face, causing swelling. Staff responded to the commotion, separated the residents, and called a Code Gray. The assaulted resident was sent to the hospital for evaluation, where swelling to the left eyebrow was noted. Multiple staff interviews confirmed the aggressive behaviors of the perpetrator, including previous incidents of violence toward staff and other residents, and the need for 1:1 monitoring upon return from the hospital. Despite the physical evidence of injury and consistent reports of aggressive behavior, the facility's internal investigation concluded the allegation was unsubstantiated, citing lack of direct witnesses and uncertainty about the intent due to the aggressor's cognitive status. However, staff statements and resident interviews consistently described a pattern of aggression and the specific incident leading to injury. The facility's policies require the prevention of abuse, but the actions taken prior to the incident were insufficient to prevent the assault and resulting injury.