Failure to Prevent Resident-on-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect multiple residents from physical abuse, resulting in significant injuries. In one incident, a resident in the memory care dining room sustained a posterior head laceration and an acute subdural hematoma after an altercation with another resident. Staff accounts indicate that two residents were struggling over a chair, leading to both falling, with one resident landing on top of the other and causing a head injury that required hospital treatment. Witnesses described one resident shoving a chair into another, causing a fall and head trauma, with visible damage to the wall and significant bleeding. Documentation from the hospital confirmed the head injury and subdural hematoma, and staff noted that the aggressor had previously shown aggression toward staff but not other residents. Another incident involved two roommates who had a history of disagreements. During an altercation, one resident fell from his wheelchair and was then kicked multiple times by his roommate. Staff intervened to separate them, and subsequent medical assessment revealed bruising consistent with defensive injuries and a fracture in the lower spine. The resident reported being kicked while on the floor, and staff and nurse practitioner documentation supported the account of physical abuse. The aggressor admitted to kicking the other resident after a verbal threat, and the victim was later discharged from the facility. The facility's records and staff interviews indicate that these incidents were not isolated and involved failures to prevent resident-on-resident abuse. The facility's abuse prevention policy affirms the right of residents to be free from abuse, but the documented events show that residents were subjected to physical harm by other residents, with staff sometimes unable to intervene in time to prevent injury. The incidents were reported to the state agency and local authorities, but the documentation reveals gaps in preventing and documenting abuse between residents.