Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in physical injury. One resident, who had a history of schizoaffective disorder, bipolar type, and moderate cognitive impairment, was involved in a verbal disagreement with his roommate, who had dementia with behavioral disturbances and moderate cognitive impairment. The disagreement centered around the use of a room light, escalating to the point where the roommate pushed the resident, causing him to lose balance and fall. This resulted in a 4-centimeter laceration to the back of the resident's head, which required immediate attention from staff. Prior to the incident, both residents had documented behavioral issues, including agitation, restlessness, and difficulty with communication or redirection. The resident who initiated the physical contact had a recent history of behavioral escalation, including irritability and verbal aggression, and had previously been transferred from another facility after an assault on another resident. Despite these known risks, the facility's interventions were limited to medication management, monitoring, and attempts at redirection, without additional measures to prevent resident-to-resident altercations. Staff interviews confirmed that there had been ongoing disagreements between the two residents about the room environment, and that the resident who pushed had become increasingly agitated in the days leading up to the incident. The facility's policy defined resident-to-resident abuse as a form of abuse, and the Director of Nursing acknowledged that the incident constituted willful harm. The facility's failure to implement effective interventions to prevent the altercation directly led to the injury sustained by the resident.