Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident was not protected from physical abuse by another resident. The incident involved one resident grabbing another by the back of the shirt and hair, causing the victim to lose balance and fall to the ground. The aggressor then made closed hand contact with the victim's face. Both residents were in a common area at the time, and the altercation was triggered by a dispute over a shirt that one resident believed belonged to them. The facility's policy defines abuse as the willful infliction of injury or mistreatment, and requires identification of residents at risk for abuse or with behaviors that might lead to conflict. The resident who was attacked had a history of multiple mental health diagnoses, including schizophrenia, adjustment disorder with anxiety, and major depressive disorder, but was assessed as having no cognitive impairment and was able to communicate effectively. The aggressor had a history of schizophrenia, bipolar disorder, traumatic brain injury, and impulse disorder, and was assessed as having moderate cognitive impairment with a pattern of delusions and aggressive behaviors. The care plans for both residents included interventions for behavioral issues and altercations, but the aggressor had a documented pattern of escalating behaviors when not on one-to-one supervision. Interviews with staff and consultants revealed that the aggressor frequently escalated to altercations when supervision was reduced, and that there was a history of such incidents. Despite this, there was a directive from corporate leadership to reduce one-to-one supervision for the aggressor, which corresponded with repeated resident-to-resident altercations. The facility's failure to maintain adequate supervision and prevent the altercation resulted in a resident being subjected to physical abuse.