Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to prevent and protect a resident from physical abuse, resulting in a significant injury. One resident, who was cognitively intact and required supervision or assistance for mobility, was identified as being at risk for abuse and had a care plan in place to ensure safe care. Another resident, with a history of severe mental illness, psychotic disorder, and aggressive behaviors, had documented episodes of verbal and physical aggression, including multiple hospitalizations for aggressive behavior and acute psychosis. Despite these known risks, the aggressive resident was able to enter a lounge area where the other resident was present. On the day of the incident, staff accounts and interviews revealed that the aggressive resident entered the lounge in an agitated state and made forceful physical contact with the other resident, who was in the process of standing up from a chair. This contact caused the resident to fall to the floor, resulting in visible injuries including swelling, abrasions, and ultimately a diagnosis of a closed fracture of the orbital wall. Multiple staff members, including a housekeeper and the Social Service Director, witnessed or responded to the incident, confirming that the aggressive resident's actions directly led to the injury. The facility's own incident report categorized the event as resident abuse. The injured resident was subsequently transferred to the hospital, where further evaluation confirmed significant facial injuries. The facility's documentation and staff interviews indicated that the aggressive resident had a known history of unpredictable and aggressive behaviors, and that there were care plans in place addressing these risks. However, the measures in place were insufficient to prevent the incident, and the facility was unable to provide video evidence due to non-functioning cameras. The failure to adequately supervise and separate residents with known aggressive tendencies from vulnerable residents led to the occurrence of physical abuse and injury.