Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident was physically assaulted by their roommate, who charged and hit them in the arm while the victim was sitting in a chair in the hallway near the nurse's station. The incident was witnessed by staff, and both residents were separated with assistance. The assaulted resident, who had moderate cognitive impairment, diagnoses including anemia, hypertension, and schizophrenia, and required partial to moderate assistance with ADLs, was assessed and found to have no injuries. The resident expressed not knowing why the attack occurred and reported feeling safe at the facility during a subsequent interview. The aggressor in the incident, who also had a diagnosis of schizophrenia and morbid obesity, was observed to have initiated the altercation by running toward and striking the other resident. After the incident, the aggressor exhibited further self-injurious behaviors, including scratching and biting their own arm, and threatened self-harm. The resident was removed from the area, monitored by staff, and eventually transported to the hospital after refusing initial treatment for minor injuries. The aggressor later stated that fear of being watched while sleeping prompted the attack, but denied wanting to harm anyone further. Staff interviews confirmed that the incident was reported and that both residents were separated following the altercation. The facility's abuse and neglect policy defines abuse to include resident-to-resident altercations and requires immediate reporting and intervention. The deficiency was identified due to the failure to protect a resident from physical abuse by another resident, as required by federal regulations.