Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in a significant injury. On the date of the incident, a resident with a history of autistic disorder, dementia, and depression entered the facility from outside and was approached by another resident diagnosed with dementia and schizophrenia. The second resident pushed the first to the floor, causing the first resident to sustain a femur fracture that required surgical repair. The incident was observed by staff, and the injured resident reported pain and was subsequently transferred to the hospital for evaluation and treatment. Review of facility records and interviews revealed that both residents had documented behavioral histories, though neither had exhibited recent physical aggression or altercations according to their care plans and assessments. The resident who committed the abuse had severe cognitive impairment and was noted to have difficulty focusing and disorganized thinking, but no recent behaviors towards others were documented. The victim had moderate cognitive impairment and required supervision for mobility, using a cane or crutch for walking. At the time of the incident, staff were present in the area, but the altercation still occurred as the two residents passed each other near an exit doorway. Facility policy states that all residents have the right to be free from abuse, and the investigation substantiated that physical abuse occurred in this case. Staff interviews confirmed awareness of the incident and described standard practices for monitoring and redirecting residents with behavioral risks. However, the actions taken prior to the incident were insufficient to prevent the physical altercation and resulting injury.