Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect residents from resident-to-resident physical abuse, resulting in one resident sustaining a nasal fracture during an altercation with another resident. Both residents involved had severe cognitive impairment and resided on a locked dementia unit. One resident had a history of physical aggression and was care planned for monitoring when approached by confused residents and for entering other residents' rooms. Despite these interventions, the aggressive resident was observed entering the other resident's room prior to the incident. On the day of the incident, a housekeeper observed the aggressive resident entering the other resident's room. Shortly after, the injured resident approached the nurse's station with a bleeding and crooked nose, stating he had been hit. The aggressive resident was seen walking behind the injured resident and had blood on his hand. Staff interviews confirmed that both residents were ambulatory and that the aggressive resident was known to wander into other residents' rooms, requiring redirection. The incident was witnessed by staff, and both residents were sent to separate hospitals for evaluation. Medical records and interviews documented that the injured resident sustained an acute nasal bone fracture with associated swelling and bruising. Both residents were evaluated by psychiatry following the incident, and no medication changes were made. The facility's abuse prevention policy affirms the right of residents to be free from abuse, but the failure to prevent this altercation resulted in physical harm to a resident.