Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse, resulting in a physical altercation between them. One resident, who had a history of schizoaffective disorder, restlessness, agitation, and generalized anxiety disorder, became agitated after being informed of a change in smoking break times. This resident exhibited escalating behaviors, including yelling, hitting walls, and slamming doors. The other resident, with diagnoses including paranoid schizophrenia, dementia, adjustment disorder, and schizoaffective disorder-bipolar type, was sitting in the activity room when the incident occurred. The altercation began after the agitated resident entered the TV area, continued to yell, and was told to be quiet by the other resident. The agitated resident then physically struck the other, leading to a fight in which both exchanged blows. Multiple staff members witnessed the incident, confirming that the initial aggressor was the resident who had been agitated over the smoking policy. Staff intervened to separate the residents, and emergency services were called. Both residents were assessed by staff and paramedics, with no visible injuries observed at the time, though one resident was sent to the hospital for evaluation of a head contusion. The facility's investigation and background checks revealed that both residents had prior histories of behavioral issues and aggression, with one resident identified as requiring closer supervision due to a moderate risk rating. Despite care plans and interventions for behavior and aggression being in place, the facility did not prevent the altercation. The report documents that the resident identified as a moderate risk was on 1:1 supervision following the incident, later reduced to 15-minute checks. However, the altercation occurred prior to these increased supervision measures. The facility's policy defines abuse as the willful infliction of injury or intimidation, including resident-to-resident altercations, and the incident met this definition as the physical abuse was deliberate and not accidental.