Resident-to-Resident Physical Abuse Resulting in Actual Harm
Penalty
Summary
A deficiency occurred when a resident with a documented history of psychiatric illness and repeated verbal and physical aggression physically assaulted another resident, resulting in actual physical injury. The aggressive resident's care plan included interventions such as redirection, coping skills encouragement, monitoring for triggers, and offering sensory tools, but these measures did not prevent the incident. On the day of the event, the aggressive resident struck another resident in the face twice with a closed fist after an altercation in the hallway, causing the victim to sustain superficial lacerations, a large hematoma, orbital fractures, and a suspected brain bleed. Prior to this incident, the aggressive resident had a pattern of similar behaviors, including striking staff, being involved in altercations with other residents, and requiring psychiatric interventions and medication adjustments. Despite these interventions and repeated staff in-services on abuse prevention and resident redirection, the resident continued to display aggressive behaviors, including pushing another resident and punching a roommate. The care plan was updated, and 1:1 supervision was initiated after previous incidents, but these actions were not sufficient to prevent the assault that resulted in significant harm. The facility's failure to ensure the safety of all residents and to prevent resident-to-resident abuse led to actual harm. The incident was reported to law enforcement, and the aggressive resident was ultimately removed from the facility. The deficiency was identified as past non-compliance, as the facility had already taken corrective actions prior to the survey.