Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Serious Injury
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in a serious incident involving two residents on the secured memory care unit. One resident, with a history of cerebral palsy, paranoid schizophrenia, mood disorder, major depressive disorder, and traumatic brain injury, exhibited severe cognitive impairment and behavioral issues. Despite care plan interventions aimed at managing aggression and ineffective coping, the resident was able to leave her room, walk down the hallway, and physically assault another resident by grabbing her arms and throwing her into a wall. This action caused the second resident, who had dementia and moderate cognitive impairment, to sustain a closed head injury, a scalp laceration, and a fractured lumbar vertebra. Staff present at the time were engaged in other duties, with one LPN at the medication cart and two CNAs occupied with other residents or outside the unit. The LPN attempted to verbally redirect the aggressive resident but was unable to prevent the assault. Witness statements confirm that staff did not anticipate the aggressive behavior, and the resident's prior history of physical aggression was not recent. The incident occurred rapidly, and staff were unable to intervene in time to prevent harm. The assaulted resident required emergency medical attention, including EMS transport, wound care, and subsequent hospitalization for her injuries. The facility's documentation and staff interviews indicate that the aggressive resident had previously displayed behavioral symptoms, including delusions and agitation, particularly when denied requests such as going outside to smoke. The care plan included specific interventions for managing these behaviors, but on the day of the incident, the escalation was not effectively prevented. The staff's inability to anticipate or immediately intervene in the resident-to-resident altercation directly led to the physical abuse and resulting injuries.