Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from abuse by another resident, resulting in a physical altercation between two cognitively intact residents. One resident entered another's room to look for a peer, and after being told the peer was not present, used derogatory language towards the resident in the room. This verbal provocation led the resident in the room to follow and physically assault the first resident in the hallway, with multiple witnesses observing the incident. Staff members, including a Certified Nursing Assistant and a Licensed Practical Nurse, confirmed seeing one resident on the floor and the other resident hitting him, with the altercation requiring staff intervention to separate the individuals involved. Both residents involved had significant medical histories, including hemiplegia, osteomyelitis, hypertensive heart disease, tumor of the bronchus and lung, Parkinson's disease, and schizophrenia. Despite their cognitive intactness as documented by BIMS scores, the altercation escalated quickly from verbal to physical abuse. The incident was witnessed by other residents and staff, and both residents provided statements confirming the sequence of events, with the aggressor admitting to physical assault in response to being called derogatory names. Facility documentation, including progress notes and resident statements, corroborated the sequence of events and the physical nature of the altercation. The facility's abuse prevention policy and residents' rights documentation affirm the right of residents to be free from abuse, yet the incident demonstrated a failure to uphold these protections. The event resulted in one resident being sent for psychiatric evaluation and the initiation of involuntary transfer proceedings for the aggressor due to endangerment of others' safety.