Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when one resident punched another in the face, resulting in swelling and discoloration near the left eye. The incident occurred after one resident became upset that another was wearing his shoes and, after asking for them to be removed without staff intervention, resorted to physical violence. The injured resident, who had a history of schizophrenia and anxiety disorder and was assessed as having severely impaired cognitive skills, was unable to recall or explain the incident during interviews. The aggressor had diagnoses of schizoaffective disorder and unspecified psychosis, with intact cognitive skills according to assessments. Staff interviews revealed that the assigned CNA did not visually assess the injured resident during night rounds, as the resident was asleep with his head covered, and the CNA preferred not to disturb sleeping residents. The LVN on duty was not informed of the incident and did not observe any abnormalities during her rounds, admitting she did not see the resident's face during shift changes. The DON confirmed that staff are expected to check on all residents face-to-face during rounds to ensure their safety. The facility's policy states that residents must not be subject to abuse by anyone, including other residents.