Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from abuse by another resident. One resident, with a history of major depressive disorder, PTSD, bipolar disorder, and severe cognitive impairment, exhibited behavioral problems including hallucinations, delusions, and a history of substance use. This resident left the facility unsupervised, returned after several hours, and reported using methamphetamine. The resident continued to display nonsensical speech, delusions, and hallucinations upon return. On the morning following the resident's return, a verbal altercation occurred between this resident and another resident with mild cognitive impairment and a history of schizoaffective disorder. The altercation escalated when the first resident swung a metal ankle foot orthosis (AFO) brace at the other resident, striking him in the head. Staff initially separated the residents after the verbal exchange but did not report the incident immediately. The situation escalated again, resulting in physical contact before staff intervened and removed the aggressor from the area. Facility documentation and staff interviews confirmed that the incident was not promptly reported after the initial verbal altercation, and the resident who committed the abuse was not immediately removed from the situation. The facility's policy states that residents have the right to be free from abuse, including physical and verbal abuse, and that staff are responsible for protecting residents from abuse by others. The failure to intervene effectively and promptly report the incident led to a resident being physically abused by another resident.