Failure to Prevent Resident-to-Resident Abuse Resulting in Serious Injury
Penalty
Summary
The facility failed to protect residents from abuse and did not provide adequate supervision to prevent a resident-to-resident altercation resulting in injury. One resident with a history of aggressive behaviors and moderate cognitive impairment had multiple prior incidents of physical altercations with other residents, including hitting and slapping, which were documented in the clinical record. The care plan for this resident included interventions such as every 15-minute checks, psychiatric and social services follow-up, and specific behavioral interventions, but these measures did not prevent further incidents. On a specific occasion, a resident with severe cognitive impairment and dependent on staff for bathroom use was struck in the face by the resident with a history of aggression. The incident was unwitnessed by staff, and the injured resident sustained a significant laceration to the temporal area, which resulted in active bleeding. The injured resident was subsequently diagnosed with a hyperacute subdural hematoma and required hospitalization, including a craniotomy and further neurological intervention. The facility's documentation indicated that the aggressive act was not substantiated as abuse due to a lack of willful intent, despite the physical evidence and medical opinion linking the injury to the altercation. The facility's abuse policy defined physical abuse as including hitting and slapping, and directed that residents should not be subjected to abuse by anyone, including other residents. Despite this, the facility did not substantiate the incident as abuse and failed to implement effective supervision or interventions to prevent the altercation and resulting injury. The monitoring interventions for the aggressive resident were discontinued prior to the incident, and the facility did not identify or implement additional interventions following the altercation that led to the severe injury.