Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical and verbal abuse by another resident who exhibited undirected behavioral symptoms and outbursts. The incident involved one resident slapping another, resulting in visible bruising on the left arm, shoulder, and hand. Documentation showed that the resident who was assaulted had multiple medical conditions, including chronic obstructive pulmonary disease, respiratory failure, anxiety disorder, and depression. The assaulted resident reported feeling unsafe and expressed reluctance to change rooms unless another roommate also moved. The facility's records indicated that the aggressor had a history of psychosis, schizophrenia, and repeated aggressive behaviors toward staff and other residents, with interventions from crisis teams and law enforcement documented. A psychiatrist had recommended 1:1 staffing for the resident with behavioral issues. Despite this recommendation, observations revealed that both residents were present together in the smoking patio without visible 1:1 staff supervision. Facility documentation and interviews confirmed that the facility was aware of the behavioral risks and the need for protective measures but failed to consistently implement them. The facility's policy stated that each resident has the right to be free from abuse, including resident-to-resident abuse resulting in physical injury, pain, or mental anguish. The Director of Nurses acknowledged the facility's responsibility to protect residents.