Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident was not protected from physical abuse by another resident. On the night in question, one resident asked another for a sexual act. When the request was refused, the first resident initially began to walk away but then returned and struck the other resident in the mouth, resulting in the loss of the victim's two top front teeth. The incident was not immediately reported to staff, and the injured resident did not inform anyone about the assault. The injury was only discovered the following morning when staff noticed the missing teeth. The resident who committed the abuse had a documented history of schizophrenia, psychotic disorder, anti-social personality disorder, delusional disorder, and severe substance use disorders. This resident also had a history of aggressive behaviors, including physical and verbal aggression, and required ongoing behavioral monitoring and support. The victim had diagnoses including sickle-cell disease without crisis, schizophrenia, and sexual dysfunction, and was described as minimally cognitively intact with moderate mood issues and no negative behaviors during the relevant assessment period. Staff interviews revealed that neither resident reported the incident at the time it occurred, and the charge nurse on duty was unaware of any altercation during the night. The staff only became aware of the abuse after observing the physical injury the next morning. The facility's own investigation concluded that the incident constituted abuse, as it resulted in injury and was unprovoked.