Failure to Prevent Resident-on-Resident Abuse
Penalty
Summary
A deficiency occurred when the facility failed to follow its abuse prevention policy, resulting in a resident being subjected to physical and mental abuse by another resident. The incident took place in the dining room, where one resident, who had a documented history of violent behavior and schizoaffective disorder, aggressively struck another resident multiple times in the head, face, and chest while she was seated. The staff member present, an LPN, was administering medications and noticed the aggressor's anxious and pacing behavior but did not remove him from the area or call for additional assistance, despite feeling that something was wrong. The attack was only interrupted after the LPN intervened by yelling and physically separating the residents. The resident who was attacked, a female with schizoaffective disorder and other medical conditions, reported experiencing pain, humiliation, fear, and emotional distress as a result of the incident. She described being shocked, scared, and embarrassed, and expressed ongoing fear of retaliation. The aggressor admitted to the attack, stating he was provoked by the victim's yelling and used physical force to make her stop. The incident was witnessed by staff, and the victim was observed to be crying uncontrollably and unable to answer questions immediately after the event. The facility's records indicate that the aggressor had a known history of physical aggression and inappropriate behaviors, including previous altercations with other residents and staff. Despite this, the staff did not take preventive measures to separate or closely monitor the resident prior to the incident, even when warning signs were present. The facility's abuse policy affirms residents' rights to be free from abuse, but the failure to act on observed behavioral changes and to ensure adequate supervision directly contributed to the occurrence of abuse.