Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. Resident 1, who had diagnoses including anxiety disorder, dementia, a history of falls, and a mental health condition with hallucinations and mood swings, was observed walking in the hallway. Resident 2, who had anxiety disorder, intellectual disabilities, and a similar mental health condition, was seated nearby and suddenly stood up and pushed Resident 1 without warning. This action caused Resident 1 to fall onto her left side, resulting in limited mobility in her left leg and hip. An x-ray confirmed an intertrochanteric fracture with varus deformity near the hip, and Resident 1 was subsequently transferred to the hospital for further care. Interviews confirmed that Resident 2 admitted to pushing Resident 1 because she was tired of hearing her voice. A licensed nurse witnessed the incident, stating that Resident 2 stood up and pushed Resident 1 with both hands, causing the fall and injury. The Director of Nursing confirmed the incident and acknowledged that all residents have the right to be free from abuse. Review of the facility's policy indicated that residents must be protected from abuse by anyone, including other residents.