Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to prevent a resident-to-resident physical assault involving two cognitively intact residents. One resident was watching television and listening to the radio when he got up to assist his roommate with a lunch tray and accidentally fell on him. This led to a verbal altercation over the volume of the TV/radio, during which both residents exchanged profanities. The situation escalated when one resident attempted to hit the other with a food tray, prompting the roommate, who was bed bound, to strike the first resident on the back/side of the head with a dumbbell. Staff were alerted to the commotion by another resident and responded immediately, finding one resident bleeding from a head injury. The injured resident was transported to the hospital by paramedics and received two staples for a laceration to the head before returning to the facility the same day. Documentation reviewed included hospital emergency department records, witness statements, and assessments for aggressive behaviors. The incident was reported as an assault, and the dumbbell used in the altercation was confiscated. Staff interviews confirmed knowledge that hitting constitutes resident-to-resident physical abuse, and records indicated that in-service training on abuse prevention had been conducted prior to the incident.