Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Serious Injury
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident, resulting in multiple incidents of resident-to-resident altercations. One resident, with a history of severe cognitive impairment, Alzheimer's Disease, and substance abuse, was physically assaulted on two separate occasions by another resident known for physical aggression, severe cognitive impairment, and behavioral disturbances. The first incident involved the aggressive resident striking the other resident in the arm twice in a common area, despite staff attempts to redirect both individuals. The second incident escalated when the same aggressive resident struck the other in the back and later in the head with a wet floor sign, causing a subdural hematoma and necessitating an ICU stay. The facility's records indicate that both residents had documented histories of behavioral issues, including wandering, aggression, and refusal of care or medications. Care plans for both residents included interventions such as redirection, monitoring, and providing calm environments, but these were either initiated after the incidents or were not effective in preventing the altercations. Staff statements and facility self-reports confirm that both residents were known to wander and become agitated, and that staff were unable to successfully redirect or separate them before the physical altercations occurred. Additionally, the aggressive resident had a pattern of refusing prescribed psychotropic and other medications, which was known to the facility and documented in the medical record. The facility's policy required immediate investigation and protective measures in cases of abuse, as well as ongoing assessment and care planning for residents with behaviors that might lead to conflict. However, the facility did not prevent the repeated physical abuse, nor did it implement effective interventions to separate or supervise the residents in a manner that would have prevented further harm. The failure to protect residents from abuse resulted in significant injury and constituted a finding of Immediate Jeopardy.