Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Serious Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in actual physical harm. Two residents, both with psychiatric and cognitive diagnoses, were sharing a room. One resident, who was cognitively intact, became verbally aggressive with his roommate, who had moderate cognitive impairment. This verbal altercation escalated, and the cognitively impaired resident struck the other in the face with a chair, causing significant facial injuries including orbital and nasal fractures. Prior to this incident, there were no documented physical altercations or behavioral changes between the two residents, and both had a history of verbal arguments but no prior physical aggression. On the day of the incident, staff were present in the hallway and initially intervened to de-escalate a verbal argument between the two residents. After the initial intervention, the residents separated briefly, but the argument resumed. As staff approached to intervene again, the cognitively impaired resident picked up a chair and struck the other resident, also hitting the intervening LPN in the arm. Immediate staff intervention followed, and the residents were separated. The injured resident sustained a skin tear, bruising, and later was found to have multiple facial fractures. The resident initially refused emergency care but was eventually sent to the hospital for evaluation and treatment after imaging revealed the extent of the injuries. The injured resident was assessed multiple times following the incident and consistently denied pain, emotional distress, or fear, and continued to participate in daily activities. Staff interviews confirmed that there were no prior indications or behavioral changes that would have predicted the escalation to physical violence. The incident was witnessed by staff, and immediate action was taken to separate and supervise both residents. The facility's failure to prevent this altercation resulted in significant physical harm to the resident.