Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Harm
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in actual harm. On 05/20/2025 at 4:09 p.m., one resident was struck multiple times on the head by another resident after refusing a request for a cigarette. This assault caused lacerations to the victim's left cheek, right cheek, forehead, and chin, requiring evaluation at the emergency room. Both residents involved did not have a prior history of physical aggression toward others, as confirmed by their medical records and staff interviews. The facility's abuse prevention policy states a commitment to protecting residents from abuse, including physical abuse such as hitting. Despite this policy, the incident occurred, and the injured resident, who had moderately impaired cognition and diagnoses including depression, anxiety, mood disorder, and seizures, suffered actual harm. The aggressor had intact cognition and diagnoses of schizoaffective disorder and major depressive disorder with psychotic symptoms. The event was substantiated through interviews, medical record reviews, and the facility's own investigation report.