Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident was subjected to physical abuse by another resident within the facility. The incident began with a verbal altercation between two residents sharing a room, which escalated when one resident punched the other twice in the face with a closed fist. The assaulted resident, who had a history of monoplegia, hemiplegia, hemiparesis, and chronic obstructive pulmonary disease, was unable to defend himself due to his physical limitations and required assistance with mobility. As a result of the altercation, the resident sustained significant facial swelling and reported severe pain, later being diagnosed with a displaced nasal bone fracture after being transferred to an acute care hospital. The resident who committed the assault had a documented history of behavioral symptoms, including verbal aggression, and was diagnosed with schizophrenia and an unspecified mood disorder. The care plan for this resident identified a potential for verbal aggression and included interventions to document observed behaviors and attempted interventions. However, the care plan did not prevent the escalation to physical aggression, and the facility failed to protect the assaulted resident from abuse. Staff interviews confirmed that the incident was witnessed, and both the LVN and CNA present identified the event as physical abuse. Facility policy explicitly prohibits all forms of abuse, including physical and verbal abuse, and emphasizes the importance of maintaining a safe environment for all residents. Despite these policies, the facility did not prevent the physical altercation, resulting in injury and psychological distress for the assaulted resident. The Director of Nursing acknowledged that the facility failed to ensure the resident was not subjected to abuse and recognized the potential for negative psychosocial effects following the incident.