Failure to Prevent Resident-to-Resident Abuse Resulting in Homicide
Penalty
Summary
A deficiency occurred when the facility failed to prevent resident-to-resident abuse, resulting in the death of one resident. The incident involved a resident with a history of schizophrenia, chronic obstructive pulmonary disease, hypertension, and brief psychotic disorder, who was initially admitted to a secured dementia unit, later moved to a behavior unit, and then returned to the dementia unit. This resident had no documented history of aggressive behaviors toward staff or other residents during their stay, and their care plan included interventions for cognitive loss and impaired judgment. Another resident, with diagnoses including major depression, bipolar disorder, severe cognitive impairment, and other medical conditions, resided on the secured dementia unit and was independently ambulatory with severe cognitive impairment noted on assessment. On the evening of the incident, staff were unable to locate the resident with schizophrenia for medication administration. After searching, staff found the resident in a room with the door closed, standing inside and perspiring. Behind a privacy curtain, another resident was found lying supine on the floor with towels and a pillowcase tightly wrapped around her neck, her face purple, and blood in her mouth. The staff immediately called for help, assessed the unresponsive resident, and contacted emergency services and law enforcement. The resident was pronounced deceased at the scene, and the cause of death was determined to be homicide by strangulation, as confirmed by the county coroner and autopsy findings. Interviews and documentation revealed that staff had last seen both residents in the hallway earlier that evening, and there was no indication of prior aggressive behavior from the resident who committed the act. The facility's policy on abuse, mistreatment, and neglect was reviewed, which defines abuse as the willful infliction of injury resulting in physical harm. The incident was investigated by police, and the resident responsible was taken into custody. The deficiency was cited for the facility's failure to protect residents from abuse, resulting in actual harm and death.