Resident-to-Resident Abuse Resulting in Physical Harm
Penalty
Summary
The facility failed to protect a resident from abuse, resulting in actual harm. A resident with a history of paranoid schizophrenia and anxiety disorder entered another resident's room and attacked her with a pen, causing multiple skin tears and penetrating wounds to the back of the head and neck. Staff responded to the incident after hearing yelling and separated the residents, finding the pen tip lodged in one of the wounds. The injured resident, who had hemiplegia and hemiparesis following a stroke, hypertension, and GERD, reported that the attacker followed her into her room, ignored her request to leave, and began the assault. Prior to the incident, both residents had attended a smoking club activity together, but staff and the residents themselves reported no interaction or altercation during the activity. Witness statements from staff confirmed that the attack was unprovoked and occurred shortly after the smoking club. Staff observed the aggressor holding the back of the victim's wheelchair and striking her in the head and neck with a pen. Immediate assessment and wound care were provided to the injured resident, who declined hospital transfer but received a tetanus shot the following day. Interviews with facility leadership indicated they were unaware of any prior issues between the two residents. The incident was reported and investigated, but the deficiency was cited due to the facility's failure to ensure residents were free from abuse, as required by policy. The event resulted in actual physical harm to the resident who was attacked.