Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Serious Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse when one resident physically assaulted another with a wheelchair foot pedal. The incident occurred when a male resident with Alzheimer's disease, seizures, and impaired memory, who was known to wander and have behavioral symptoms, entered another resident's room. The second resident, also diagnosed with Alzheimer's disease and a history of aggression, struck the first resident multiple times with a wheelchair leg rest, resulting in lacerations to the scalp, right hand, and right forearm, as well as a worsening subdural hematoma with a midline shift. The assault was witnessed by an LVN, who found the injured resident on the floor and the aggressor holding the weaponized foot pedal. Prior to the assault, the resident who was attacked had already been sent to the emergency room earlier that day for a fall resulting in a laceration and a diagnosed subdural hematoma. After returning to the facility, the resident was assaulted, leading to further injuries and a significant increase in the severity of the brain bleed, as confirmed by emergency department records and CT scans. The resident required transfer to another hospital for a higher level of care due to the increased intracranial pressure. The aggressor resident had a documented history of aggression, was on antipsychotic medication, and was known to be territorial about his space. Both residents were on a secured unit due to wandering and behavioral issues. The incident was reported to the DON and Administrator, and staff interviews confirmed that only one staff member was present in the secured unit at the time. The staff member responded to noises and discovered the assault in progress, but was unable to immediately separate the residents due to being alone. The facility's abuse policy prohibits abuse by anyone, including other residents, but the failure to prevent this altercation resulted in serious harm.