Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Serious Injury
Penalty
Summary
The facility failed to protect two residents from physical abuse, resulting in one resident sustaining a complex left hip fracture that required surgical intervention. One resident, who had diagnoses including schizophrenia, major depression, dementia, and chronic kidney disease, was involved in an altercation with another resident on the smoking patio. The altercation began with verbal exchanges and escalated when one resident pushed the other out of his wheelchair, causing him to fall onto the concrete and sustain a serious hip injury. Witnesses confirmed that the incident involved bickering, followed by one resident tipping the other out of the wheelchair. The injured resident was unable to stand due to pain and was subsequently sent to the emergency room, where a complex fracture was confirmed. The resident who initiated the altercation had a documented history of socially inappropriate behaviors, including verbal and physical aggression, and a delusional thought process affecting his awareness of safety for himself and others. The facility's Abuse Prevention Program defines abuse as the willful infliction of injury, and the incident was described by staff as an impulsive act rather than abuse. However, the event resulted in significant harm to the resident, and another resident was also struck in the face during the altercation. The report documents that the facility did not prevent the physical abuse between residents, as required by their policies.