Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with severe cognitive impairment and significant physical care needs was subjected to physical abuse by another resident. The incident occurred in the facility's smoking area, where the aggressor pulled the victim's hair, struck her in the back of the head, and pushed her wheelchair into a fence. The victim immediately experienced pain and reported the incident to several nursing staff, though she could not recall exactly whom she told. The victim also contacted a family member, expressing fear for her safety, especially after the aggressor threatened her the following day. The family member attempted to reach the facility but, unable to get a response, contacted the Sheriff's department to conduct a welfare check. Multiple staff interviews confirmed that the victim reported the abuse shortly after it occurred, with several nursing assistants recalling the resident's complaints of being hit and having her hair pulled. The aggressor admitted to grabbing the victim by the hair and shaking her during a verbal altercation. Documentation showed that the victim had a pain level of ten and required medication for her symptoms. The aggressor had a history of behavioral issues, including previous verbal altercations and threats, and had recently experienced a medication change that increased his discomfort and irritability. Despite the victim's immediate reports to staff, there was a delay in administrative awareness and response. The charge nurse on duty did not recall the incident, and the director of nursing was not informed until the following day. The facility's policy required protections against abuse, but the events indicate a failure to prevent and promptly address resident-to-resident physical abuse, resulting in the victim's decision to leave the facility against medical advice due to ongoing fear and lack of perceived safety.