Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect residents from abuse, resulting in a physical altercation between two residents. One resident, who had a history of TIA, cerebral infarction, osteoarthritis, COPD, heart disease, schizophrenia, and bipolar disorder, and was moderately cognitively impaired, was physically assaulted by another resident who was cognitively intact and had multiple chronic conditions. The incident occurred when the assaulted resident was walking toward the nursing station and became involved in a verbal altercation with the other resident. Despite attempts by a CNA to separate them, the aggressor pushed the other resident, causing a fall and a laceration to the head that required stitches and hospital evaluation. Staff interviews and documentation confirmed that the residents were engaged in a verbal dispute, and staff intervention was insufficient to prevent the physical assault. The facility's abuse prevention policy requires residents to be free from abuse, neglect, and mistreatment, but this policy was not effectively implemented in this instance. The incident was captured on camera, and statements from staff and residents corroborated that the physical contact led to injury. The event was reported to the police, and the injured resident received medical attention for the head wound.