Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure a resident's right to be free from abuse when one resident physically assaulted another. The incident occurred when a resident with moderate cognitive impairment and a history of psychiatric diagnoses approached another resident, who had severe cognitive impairment, hemiplegia, and required substantial assistance with mobility. The aggressor grabbed the other resident's head, hit it against the wall several times, and then punched him in the face with a closed fist. Staff intervened during the incident, but not before the assault had occurred. The assaulted resident was found to have a bruise near his left eye and cheek, but denied pain or discomfort. He was assessed by nursing staff, and his vital signs were recorded. The resident did not recall the incident after the day it occurred and did not display fear or withdrawal in the aftermath. The aggressor had no documented history of physical aggression prior to this event, and staff and social services confirmed that no such behaviors had been reported by the previous facility or responsible party. Witnesses indicated that the incident may have been triggered by a gesture or comment, but the physical assault was unprovoked and unexpected based on prior behavior. Both residents had care plans addressing behavioral issues, but the interventions in place did not prevent the altercation. The facility's policy defines abuse as the willful infliction of injury, including resident-to-resident altercations, and requires protections to prevent such events. Despite monitoring and behavioral interventions, the facility did not prevent the physical abuse, resulting in harm to a resident.