Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from physical abuse by another resident. The incident involved a resident with hemiplegia, major depressive disorder, and cataracts, who was found with multiple superficial wounds and blood on his face after being struck by his roommate. The aggressor, who was cognitively intact and had diagnoses including cellulitis and diabetes, admitted to hitting the victim following a verbal altercation involving a racial slur. The incident was not directly witnessed by staff, but was reported by another resident who heard the altercation and alerted a CNA. Upon entering the room, the CNA observed the aftermath, with the victim wheeling himself into the bathroom and the aggressor walking away. Clinical documentation and staff interviews confirmed that the injured resident sustained lacerations to the forehead, nose, lip, and chin, but was not transferred to the hospital. The aggressor left the facility against medical advice the same day. The facility's investigation concluded that the event was unanticipated and isolated, occurring in an area with adequate staff supervision. However, prior to the incident, there were indications of behavioral issues, as the aggressor had been observed yelling at another resident the day before. Facility policies reviewed indicated that residents have the right to be free from all forms of abuse, including physical abuse. Despite these policies, the facility failed to prevent the physical altercation between the two residents, resulting in injury. Staff interviews revealed an understanding of abuse protocols, but the incident still occurred, demonstrating a lapse in protecting resident rights as required by both facility policy and regulatory guidelines.