Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse when two residents were involved in a physical altercation. One resident, who was cognitively intact and had diagnoses including hypertension, COPD, and schizophrenia, was outside during a smoke break when another resident approached and struck them in the face. The incident resulted in a bloody lip and an abrasion to the elbow after the resident fell to the ground. The resident denied pain or discomfort but required first aid for the injuries. The altercation was unprovoked, and the resident who was attacked did not retaliate. The resident who initiated the altercation was also cognitively intact and had a history of delusions, epilepsy, anxiety disorder, depression, psychotic disorder, COPD, and schizophrenia. This resident reported that the attack was motivated by the belief that the other resident was gay, as indicated by their choice of clothing. Staff interviews confirmed that the attack was sudden and unexpected, occurring while staff were present but momentarily distracted by routine duties such as letting other residents outside and distributing cigarettes. The staff intervened quickly once the altercation began, but were unable to prevent the initial assault. Multiple staff members and both residents provided consistent accounts of the event, describing how the aggressor walked directly up to the other resident and began striking them without provocation. The incident occurred in a common area near the back door, with staff nearby but unable to anticipate the aggressor's actions. The facility's policy required staff to identify residents at risk for abuse and to implement care planning to reduce the chances of mistreatment, but in this case, the measures in place did not prevent the altercation.