Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident was not protected from physical abuse by another resident. One resident, who had a diagnosis of metabolic encephalopathy and intact cognition but was dependent on staff for bed mobility, was attacked in his room by another resident diagnosed with metabolic encephalopathy and schizophrenia, with moderately impaired cognition and requiring substantial assistance with activities of daily living. The attacking resident entered the victim's room, yelled accusations, threw a banana, and struck the resident multiple times with a plastic water pitcher and her fists. The incident resulted in the victim sustaining a 1 cm x 0.5 cm abrasion on the right side of his forehead, multiple areas of redness on his forehead and right forearm, and required immediate first aid for seven days. The event was witnessed by staff and another resident. Staff responded to yelling and screaming, finding the aggressor in the victim's room, and intervened to separate the two. The aggressor was described as very combative and continued to yell and scream even after being removed from the room. The victim reported feeling shocked and scared, using his arms and a blanket to protect himself during the attack, and called for help until staff arrived. The aggressor accused the victim of giving her a shot and raping her, according to both staff and another resident who witnessed the incident. Documentation reviewed included admission records, Minimum Data Sets, change of condition forms, skin integrity sheets, and treatment administration records, all confirming the injuries and the sequence of events. The facility's policy on abuse, neglect, and exploitation states that residents should not be subject to abuse by anyone, including other residents. However, in this instance, the facility failed to prevent one resident from physically abusing another, resulting in physical injury and emotional distress.