Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from physical abuse when another resident stomped on his foot in the dining room. The incident occurred when one resident, who had a history of behavioral symptoms directed at others and required secure unit placement, exhibited aggressive behavior by stomping or kicking another resident's foot. The affected resident had diagnoses including schizoaffective disorder, autistic disorder, and cognitive communication deficit, and was assessed as having moderately impaired cognition. The aggressor had diagnoses of intellectual disability, cognitive communication deficit, and bipolar disorder, with severely impaired cognition and a documented history of behavioral symptoms toward others. Staff observations and interviews confirmed that the aggressive resident attempted to stomp on the other resident's foot multiple times before staff could intervene and separate them. The resident who was stomped on moved his feet away and later denied pain or discomfort, with a light bruise noted on his right foot. Staff present at the time reported the incident and performed an assessment, confirming the injury. The aggressive resident admitted to stomping on the other resident's foot out of meanness and expressed emotional distress related to missing his parents and wanting to leave the facility. Review of care plans and staff interviews indicated that interventions for monitoring and redirecting the aggressive resident were in place, and staff had received training on abuse, neglect, and resident-to-resident altercations. However, despite these measures, the incident occurred, resulting in physical abuse and a bruise to the affected resident. The facility's policy prohibits and aims to prevent abuse, neglect, and exploitation, but the failure to prevent this altercation led to the deficiency.