Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with a documented history of serious mental illness, including schizophrenia, bipolar disorder, and intermittent explosive disorder, was admitted to the facility with known aggressive and assaultive behaviors. The resident's PASRR and care plan indicated a need for 24-hour protective oversight and specific environmental and supervision interventions to prevent harm to self or others. Despite these documented needs, the resident was on 15-minute face checks rather than continuous supervision at the time of the incident. On the day of the event, the resident entered a vending room where two other residents were present. Without provocation, the resident forcefully slammed another resident's head against a vending machine and struck the resident multiple times in the face with a closed fist. The assaulted resident sustained lacerations to the right eyebrow and upper lip, both requiring sutures. Multiple witness statements and progress notes confirmed the unprovoked nature of the attack and the injuries sustained. The facility's abuse and neglect policy required assessment, care planning, and monitoring of residents with behaviors that might lead to conflict, as well as sufficient staff deployment and supervision to prevent abuse. However, the interventions in place at the time did not prevent the resident with a known history of violence from attacking another resident, resulting in physical harm that met the facility's definition of abuse.