Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse when one resident pushed another to the floor, resulting in a head injury that required hospital evaluation and treatment. The incident occurred when a resident with a history of major depressive disorder, type 2 diabetes mellitus, and paranoid schizophrenia was talking with another resident in the hallway. Another resident, who had diagnoses including bipolar disorder, Alzheimer's disease, schizophrenia, and Parkinson's disease, approached and pushed the first resident to the floor without provocation. The injured resident sustained a 1.0-inch laceration to the back of the head, which required two staples at a general acute care hospital. Record reviews indicated that both residents involved had moderately impaired cognitive skills and required assistance with activities of daily living. The resident who was pushed had a documented history of agitation and aggressive behaviors, and was noted to lack the capacity to make reasonable decisions, requiring redirection. The resident who pushed also had a history of agitation and aggressive behaviors, lacked capacity for medical decisions, and required redirection. The incident was witnessed by staff, who observed the push and responded by providing immediate first aid and calling emergency services. The facility's policy prohibits abuse, mistreatment, and neglect, and specifies that residents who threaten or attack others should be removed from the situation. Despite these policies, the incident occurred, resulting in physical harm to a resident. The deficiency was identified through interviews, record reviews, and direct observation of the incident and its aftermath.