Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Hospitalization
Penalty
Summary
A deficiency occurred when a resident with a history of schizophrenia, antisocial personality disorder, intermittent explosive disorder, and other mental health conditions physically assaulted another resident, resulting in significant facial injuries that required hospitalization. The aggressor resident was known to have mild cognitive impairment and a care plan that identified risks for physical or verbal aggression, delusions, hallucinations, and irritability. The care plan also noted the need for staff to be aware of the resident's body language and to provide protective oversight while maintaining the least restrictive environment. Despite these identified risks, the resident was able to enter another resident's room and inflict harm. The assaulted resident had intact cognition but significant physical limitations, including a left leg above-the-knee amputation and diagnoses such as Parkinson's disease, osteomyelitis, and HIV. This resident required substantial assistance with activities of daily living and was unable to defend themselves during the incident. The attack resulted in lacerations and facial fractures, as documented by both facility and hospital records. The injured resident reported feeling scared and unable to defend themselves due to physical weakness. Staff documentation and interviews confirmed that the aggressor resident self-reported the incident to staff, who then found the injured resident with facial wounds and bleeding. Prior to the incident, there had been no reported issues between the two residents, and staff had not observed any prior aggressive behavior from the aggressor. The facility's policies required identification and intervention in situations where abuse was likely, as well as protective oversight for residents at risk of aggressive behavior. However, the incident demonstrated a failure to prevent resident-to-resident abuse, resulting in harm.