Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by other residents, resulting in one resident sustaining blunt head trauma and a swollen, black eye. In the first incident, a female resident with a history of confusion, memory loss, wandering, and lack of safety awareness was punched in the right eye by a male resident who was known to have persistent anger, poor judgment, psychotic symptoms, and a history of aggressive and abusive behaviors. The incident occurred in the activity room during a group activity, where only one activity aide was present. The male resident became upset, was not redirectable, and struck the female resident before staff could intervene. The injured resident was sent to the emergency department for evaluation and treatment of blunt head trauma, and the incident was reported to the police and the state health department. In the second incident, a resident with a history of cerebral infarction and diabetes was slapped on the head by a roommate who had a history of substance abuse, poor judgment, and aggressive behaviors. The altercation occurred when the resident entered the bathroom connected to their shared room, leading to a confrontation in which the aggressive resident slapped the other on the head. The victim reported previous verbal aggression from the roommate but stated this was the first physical incident. Staff were alerted by the altercation, and the police were called, resulting in a citation for the aggressor. The aggressive resident was placed on 1:1 monitoring until discharge, and the incident was documented in nursing and social service notes. Both incidents involved residents who had been previously identified as at risk for abuse, with care plans in place noting their vulnerabilities and behavioral histories. Despite these assessments and care plans, the facility did not prevent the physical altercations, and staff were unable to intervene in time to stop the abuse. The facility's abuse prevention policy affirms the right of residents to be free from abuse, but the events described demonstrate a failure to ensure this protection for the residents involved.