Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Harm
Penalty
Summary
The facility failed to protect residents' right to be free from physical abuse by another resident, resulting in actual harm to two residents. One resident, who was cognitively intact and dependent on staff for transfers, was involved in a physical altercation with a roommate, also cognitively intact but requiring supervision for mobility. The incident occurred in their shared room, where staff responded to a commotion and found one resident on the floor and both holding a walker. Both residents sustained injuries: one had a swollen jaw and a hematoma, while the other had a bleeding head and a fractured hand. Both were sent to the hospital for evaluation and treatment. Prior to the incident, there were indications that one resident was afraid of the other, and it was reported that the aggressive resident had previously attacked another person. The altercation was triggered when a visitor entered the room, and a misunderstanding led to one resident becoming angry and striking the other with a walker. Staff interviews confirmed that the injured resident was found on the ground, screaming for help, while the aggressor was standing over them. Law enforcement was notified, but no immediate threat was determined since the injured resident was transferred out of the facility. Medical records and interviews revealed that the injured resident was later transferred to another facility due to a blood infection affecting the spine and subsequently passed away in the hospital. The aggressive resident admitted to punching the roommate and was later involved in another episode of aggression toward staff. The facility's policy required the prevention of abuse, neglect, and exploitation, but the events leading up to and during the altercation demonstrated a failure to protect residents from physical abuse.