Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse when one resident struck another on the head with a rock, resulting in a laceration and a hospital visit. The incident occurred outside during a supervised smoke break, where one resident became agitated at another and, after a verbal altercation, threw a rock intended for a different resident but instead hit a third resident. The injured resident sustained a 3 cm laceration to the back of the head and required hospital evaluation due to being on blood thinners. Prior to the incident, the resident who threw the rock had a documented history of altercations with other residents, including being the instigator in a previous dispute and having another altercation just days before the event. Care plans and assessments noted these behavioral issues, and interventions such as increased supervision and trauma-informed assessments were implemented after previous incidents. However, despite these measures, the resident was able to access an area where rocks were present and engage in another altercation. Interviews and record reviews confirmed that the resident who threw the rock was cognitively intact but had a history of mood and anxiety disorders, as well as a history of behavioral issues with peers. The injured resident was also cognitively intact and had no involvement in the altercation prior to being struck. The facility's policies defined abuse to include resident-to-resident altercations resulting in physical harm, and the incident met this definition as the action was deliberate, even if not intended to harm the specific resident who was injured.