Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in a significant injury. On one occasion, two male residents with BIMS scores of 15/15 and histories of behavioral issues had an argument in the dining room, which was stopped by a nurse before it became physical. The following day, while on the smoking patio with approximately 15 people present, one resident sprayed a substance into the other's face, causing the second resident to fall and hit his head on a metal bench. This resulted in a 3.2 cm laceration to the top of the head, requiring 8 staples at the hospital. The incident was witnessed by staff and other residents, and the injured resident reported being unable to see after being sprayed, leading to the fall and injury. Both residents had prior incidents and were care planned for abuse potential following the initial altercation. After the first argument, the facility moved one resident to another room and increased monitoring of both individuals. Despite these measures, the second altercation occurred, resulting in physical harm. Staff responded to the code gray, provided first aid, and called 911. The injured resident was treated at the hospital and later readmitted, while the aggressor was discharged from the facility. The facility's policy prohibits abuse, neglect, and mistreatment, but the measures in place did not prevent the incident.