Failure to Protect Resident from Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse inflicted by another resident, resulting in a serious injury. Two residents were involved in a physical altercation in a common area, during which one resident was beaten by the other. The assaulted resident, who had moderately impaired cognition and was independent with sit-to-stand transfers, lost balance during the altercation, fell to the floor, and sustained a displaced intertrochanteric fracture of the left femur, requiring surgical repair. Documentation indicates that the resident was sitting in a wheelchair in the TV area when the other resident approached and began hitting them, leading to the fall and subsequent injury. The resident who initiated the altercation had diagnoses including anxiety and major depressive disorder, with moderate cognitive impairment. During the incident, this resident was observed striking the other resident multiple times and throwing objects. Staff intervened after the altercation had already escalated, and emergency services were called. The resident who was assaulted was transported to the emergency room for evaluation and treatment of the leg fracture, while the aggressor was later transferred to a mental health facility for psychiatric evaluation and treatment. Prior to the incident, there was no evidence of behavior management training for staff, and the facility's abuse and neglect policy was not effectively implemented to prevent the altercation. The incident was documented in nursing notes and care plans, and interviews confirmed that staff had not received relevant training before the event. The deficiency centers on the facility's failure to ensure the safety of residents from physical abuse by another resident, resulting in significant harm.