Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in one resident being physically assaulted by another. The incident involved a resident with a history of hemiplegia, hemiparesis, cognitive communication deficit, and mood disorder, who was punched in the face by his roommate, a resident with diagnoses including bipolar disorder with psychotic features and intermittent explosive disorder. Prior to the altercation, there were documented verbal disagreements and escalating tensions between the two residents, including complaints about noise and mutual accusations of disruptive behavior. Staff were aware of at least one verbal disagreement the day before the physical altercation, but the residents were not separated or further interventions implemented to prevent escalation. On the night of the incident, the two residents engaged in a heated exchange that escalated to physical violence. One resident reported being struck in the mouth and chest, and sustaining a skin tear and scratches. Both residents provided accounts of the altercation, with each blaming the other for initiating the physical aggression. Staff interviews confirmed that the altercation was preceded by loud arguments and that a nurse intervened by removing one resident from the room, but the other resident followed and delivered a punch in the hallway. The facility's Director of Nursing and Assistant Director of Nursing acknowledged that there was prior knowledge of the residents' incompatibility and that the incident could have been prevented if staff had been informed of the escalating conflict. The facility's abuse and neglect policy requires prompt recognition, reporting, and investigation of abuse, including resident-to-resident altercations. However, the report indicates that staff did not act on early warning signs or previous behavioral history, such as the new resident's involvement in a prior altercation at another facility and the ongoing complaints from the other resident about his roommate. The lack of timely intervention and failure to separate the residents after initial signs of conflict directly contributed to the physical abuse incident.