Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse, resulting in one resident stabbing another multiple times in the back with an ink pen. Both residents involved had documented histories of cognitive or behavioral issues, including dementia, major depressive disorder, anxiety disorder, epilepsy, and cerebral palsy. Prior to the incident, there were documented altercations between the two, including an argument over a jacket that led to scratching and verbal aggression. The care plans for both residents noted a history of being both recipients and aggressors of verbal and physical aggression. On the day of the incident, one resident reported being stabbed in the back with a pen by the other after a confrontation in another resident's room. The resident who was stabbed was found to have ten superficial puncture wounds on her upper back and shoulder. The resident who did the stabbing claimed it was in self-defense after being punched in the forehead by the other resident, an injury that was later observed as a large healing bruise. Both residents were sent to the emergency room for evaluation following the incident. Interviews and record reviews revealed that staff were not aware of the forehead injury until after the stabbing incident was reported. The resident with the bruise did not report the injury to staff at the time it occurred. There was no documentation in the emergency room records regarding the alleged punch or a psychiatric evaluation for the resident who was stabbed. Both residents were subsequently placed under one-to-one supervision, and their rooms were separated to prevent further interactions.