Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, as required by its abuse prevention policy. One resident, who had a history of schizoaffective disorder, legal blindness, and severely impaired cognition, was involved in a verbal exchange with another resident. During this interaction, the second resident pushed the first, causing the resident to fall to the floor. The incident was unwitnessed, but the injured resident reported being pushed, and this was corroborated by the other resident's admission and staff observations immediately following the event. Following the fall, the injured resident complained of pain and was assessed by staff, who noted significant discomfort and inability to get up. The resident was transferred to a general acute care hospital for evaluation, where imaging confirmed an acute comminuted fracture of the right 5th metacarpal. Staff interviews and documentation indicated that the resident who pushed the other had a disagreement and admitted to the physical act, with staff witnessing the aftermath and hearing the resident verbally acknowledge the push. The facility's policy and procedure on abuse prevention explicitly states that residents must be protected from abuse, including by other residents. Despite this, the incident occurred, resulting in physical harm to a resident with significant cognitive and physical vulnerabilities. The documentation and interviews confirm that the facility did not prevent the abusive act, leading to the resident's injury.