Failure to Prevent Resident-on-Resident Physical Abuse in Elevator
Penalty
Summary
A resident with a history of epilepsy, cerebral infarction, and moderate cognitive impairment was physically attacked by another resident with severe cognitive impairment and multiple behavioral diagnoses while in a crowded elevator. The aggressor, a male resident with a history of behavioral and emotional disorders, struck the victim in the head multiple times with a cane following a verbal altercation. Witness statements confirm that verbal threats were made prior to the physical assault. The victim sustained a scratch on the head and was subsequently sent to the hospital, where she was diagnosed with a minor closed head injury and experienced ongoing emotional distress and anxiety related to the incident. The facility's records indicate that the victim had a care plan noting a history of suspected abuse and factors increasing her susceptibility to abuse or neglect. Despite this, the facility failed to prevent the assault, and the victim reported feeling unsafe and targeted by other residents following the incident. The aggressor was sent for psychiatric evaluation but returned to the facility before leaving against medical advice. The facility's abuse prevention policy states a commitment to protecting residents from abuse by anyone, but this policy was not effectively implemented in this case.