Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from abuse, resulting in one resident sustaining multiple injuries after being pushed by another resident. The incident occurred when one resident, who had a documented history of aggressive and assaultive behaviors, reacted to being bumped in the hallway by forcefully pushing the other resident into a wall, causing an abrasion to the forehead and a laceration to the left eyelid. The injured resident required assessment and was sent to an acute care hospital for further evaluation, where imaging revealed a cervical spine injury. Prior to the incident, the aggressive resident had a known history of similar behaviors, including previous assaults on peers at both the current and prior facilities. Documentation indicated that this resident had been placed on 1:1 supervision in the past due to high risk for violence and had requested a unit change, expressing ongoing frustration with the other resident's behavior. Despite these known risks and repeated requests for separation, the two residents were not adequately separated, and the aggressive resident was not moved to another unit. Staff interviews and medical record reviews confirmed that the aggressive resident had previously assaulted the same peer and had communicated intentions to harm if the situation persisted. The facility's policies required identification and intervention in situations where abuse was likely, as well as immediate reporting and investigation of such incidents. However, the facility did not implement sufficient measures to prevent further altercations, resulting in the resident's injuries.