Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with amyotrophic lateral sclerosis, dysphagia, and cachexia, who was cognitively intact but physically dependent and used a wheelchair, was struck in the face by another resident in the facility's smoking area. The incident was reported by the affected resident, who stated that the other resident approached, used expletives, and slapped her on the left side of her face. Documentation indicated that the resident experienced swelling and redness to the left side of her face and a sore to her lower lip that reopened after the slap. The resident expressed psychosocial distress, fear, and a sense of being unsafe in the facility following the incident. The resident who committed the act had a history of hemiplegia, hemiparesis, diabetes, aphasia, and severe cognitive impairment. This resident was unable to provide a clear account of the incident due to communication difficulties. Witnesses, including another resident, confirmed observing the physical altercation, stating that the aggressor willfully struck the victim on the cheek. Staff interviews corroborated that the incident took place in the smoking area and that the aggressor had previously exhibited aggressive behavior. Facility records and staff interviews revealed that, prior to the incident, there were no effective measures in place to prevent the altercation or to monitor the residents for aggressive or inappropriate behaviors as outlined in the facility's abuse prevention and resident-to-resident altercation policies. The affected resident reported ongoing fear and discomfort, noting that the aggressor continued to be present in areas near her room after the incident, which contributed to her distress. The facility's failure to protect the resident from physical abuse resulted in both physical and psychosocial harm.