Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when one resident physically assaulted another in a common area. The incident occurred when a resident with a history of disorganized schizophrenia, major depressive disorder, and substance abuse approached another resident from behind and struck them in the head and neck, knocking them to the floor, and then proceeded to kick and stomp on the resident's head and body multiple times. The assaulted resident sustained bruising on the forehead, minor swelling on the back of the head and neck, and a small scratch on the left cheek. Multiple staff and resident witnesses confirmed the violent nature of the attack, and the assaulted resident urinated on themselves during the incident. Both residents involved had significant psychiatric histories, including schizophrenia and anxiety disorders. The resident who committed the assault was documented as cognitively intact on the most recent assessment and had a care plan indicating a history of behavioral challenges requiring protective oversight. The assaulted resident was cognitively impaired and had a care plan addressing anxiety and behavioral symptoms, with interventions to monitor and de-escalate anxiety-related behaviors. Despite these documented risks and interventions, the facility did not prevent the physical altercation from occurring in a supervised area shortly before lunch. Interviews with staff and residents revealed that the altercation was witnessed by several individuals, including the Business Office Manager and the Activities Director, who described the attack as violent and unprovoked. The facility's abuse and neglect policy defined abuse as the willful infliction of injury or pain, including resident-to-resident altercations. However, some facility leadership expressed uncertainty about whether the incident constituted abuse, citing the aggressor's mental state and possible provocation. The police were called, and the aggressor was arrested and charged with assault. The incident was reported to the guardian of the assaulted resident and local law enforcement.