Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from physical abuse by another resident. During a scheduled smoke break, one resident touched another on the shoulder and then struck the resident on the buttocks twice, with the second strike being harder and causing pain. The affected resident immediately reported the incident to the charge nurse, stating that the contact was inappropriate and made them feel violated. The incident was witnessed on video footage, and the resident who committed the act was found to be intoxicated at the time. The resident who was abused had a history of borderline intellectual functioning and paranoid schizophrenia but was assessed as cognitively intact. The resident who committed the abuse had diagnoses of alcohol abuse and adjustment disorder and was also assessed as cognitively intact. The abused resident reported that the incident triggered memories of a previous sexual assault and described the contact as sexual in nature due to its inappropriateness. The resident also noted the smell of alcohol on the other resident's breath and observed signs of intoxication. The facility's abuse and neglect policy defines abuse as the willful infliction of injury or pain, including resident-to-resident altercations. The investigation determined that the incident constituted abuse, as the contact was both unwanted and caused physical pain and emotional distress to the resident. The facility's records and interviews confirmed the sequence of events and the impact on the resident involved.