Failure to Prevent Resident-to-Resident Abuse Resulting in Serious Injury
Penalty
Summary
The facility failed to protect a resident from abuse when another resident physically assaulted them, resulting in significant injury. Specifically, one resident pushed another to the ground and kicked them in the head while they were down. This altercation led to the injured resident being sent to the emergency room, where they were diagnosed with a nondisplaced spiral fracture of the right humerus. The incident was witnessed by staff, who responded after hearing a commotion and observing the assault in progress. The resident who was assaulted had a complex medical and psychiatric history, including schizophrenia, PTSD, autistic disorder, schizoaffective disorder, bipolar disorder, generalized anxiety disorder, and ADHD. Their care plan indicated a need for 24-hour supervision due to the severity of their behaviors and mental illness symptoms, as well as a history of aggression and anxiety. The resident was known to require assistance with activities of daily living and was at risk for aggressive outbursts and anxiety-related behaviors. The resident who committed the assault also had a history of psychiatric diagnoses, including schizophrenia, bipolar disorder, schizoaffective disorder, and impulse control disorder. Their records documented recent aggressive and threatening behaviors, including physical aggression towards staff and others, poor impulse control, and a history of violence. At the time of the incident, staff were not aware of any issues between the two residents until after the altercation occurred. The facility's failure to prevent this altercation resulted in a serious injury to one resident.