Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Harm
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in actual harm. On the specified date, one resident with a history of cerebral infarction, hemiplegia, diabetes, and schizoaffective disorder, and with moderately impaired cognition, attempted to prevent his roommate from leaving their shared room. This interaction escalated into a physical altercation, during which the resident was struck in the face by his roommate, resulting in facial bruising and a contusion that required emergency department evaluation and treatment. Prior to the incident, multiple staff members, including CNAs, were made aware of escalating threats of physical harm from the aggressor resident, who had a history of bipolar disorder, intellectual disabilities, and severely impaired cognition. These threats were reported to an LPN and subsequently to the DON. Despite these warnings, no new interventions or orders were obtained, and the primary care provider or nurse practitioner was not notified of the threats. The administrator was also not informed of the behavioral issues or threats prior to the altercation. The facility's policy on abuse prevention and prohibition was not followed, as residents must not be subject to abuse by anyone, including other residents. The lack of timely intervention and communication among staff and leadership contributed to the failure to prevent the physical abuse, resulting in actual harm to the resident.