Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to ensure that a resident was free from physical abuse by another resident, resulting in a significant incident in the dining room. Early in the morning, a non-verbal resident with a low BIMS score and multiple psychiatric diagnoses, including delusional disorder, schizophrenia, and intellectual disability, stood up from his wheelchair, lost his balance, and fell to the floor. While attempting to get up, he inadvertently grabbed the forearm of another resident who was seated nearby. Startled by the contact, the second resident attempted to pull her arm away, which led to her arm pressing against the first resident's mouth, resulting in a human bite to her right forearm. The incident was witnessed by staff and other residents, who confirmed that the biting occurred quickly as the first resident tried to regain his balance. The injured resident was immediately escorted to the nurse's station, evaluated, and sent to the hospital for further assessment and treatment, which included antibiotics and a tetanus shot. The wound was described as a full-thickness, open area with no signs of infection at the time of evaluation. The biting resident was also assessed and transferred to the hospital for psychiatric evaluation. Prior to the incident, the biting resident had a documented history of physical abuse toward staff and other residents, related to poor impulse control, and his care plan had been revised to reflect these behaviors. The facility's policy affirms the right of residents to be free from abuse and outlines steps for prevention and reporting, including immediate evaluation and separation of residents involved in altercations. Despite these policies and the known behavioral risks, the incident occurred, resulting in physical harm to a resident.