Failure to Prevent Resident-on-Resident Physical Abuse Due to Inadequate Implementation of Abuse Policy
Penalty
Summary
The facility failed to implement its policy and procedure regarding the identification and prevention of abuse, resulting in a serious incident involving two residents. One resident, with a history of hypertension, bilateral hearing loss, type 2 diabetes, and hypercalcemia, and who was cognitively intact but required assistance with activities of daily living, was physically assaulted by another resident. The assault occurred after staff heard a loud noise and discovered the resident on the floor, being kicked and stomped on the head by another resident. The injured resident sustained significant injuries, including swelling to the forehead, a suspected zygomatic arch fracture, traumatic injury to the right ear and temple, temporary unconsciousness, and bleeding, necessitating transfer to an acute care hospital for treatment and subsequent readmission to the facility. The resident who committed the assault had diagnoses including paranoid schizophrenia, mood affective disorder, hypertension, and type 2 diabetes, and was noted to have severely impaired cognitive skills but was independent with activities of daily living. This resident had a care plan addressing non-compliance with treatment, specifically refusal of prescribed antipsychotic medication (Haldol), which was documented as refused daily for over two weeks prior to the incident. Staff interviews confirmed that the resident's refusal of medication was known and that the risk of aggression due to non-compliance was recognized, yet the facility did not take effective action to mitigate this risk or prevent the assault. The facility's policy, which strictly prohibits any form of resident abuse, was not effectively implemented in this case. Staff were aware of the resident's escalating paranoia, delusions, and refusal of antipsychotic medication, but failed to prevent the resulting physical abuse. The incident was directly observed by multiple staff members, who confirmed the sequence of events and the severity of the injuries sustained by the assaulted resident.