Resident-to-Resident Physical Abuse Resulting in Serious Injury
Penalty
Summary
A deficiency occurred when a resident sustained serious injuries, including fractures to the humerus and femur, as a result of being physically abused by another resident. The incident took place when one resident, who had a history of dementia with behavioral disturbances and bipolar disorder, entered another resident's room and pushed her after an altercation over the bathroom. Both residents involved were severely cognitively impaired, with documented histories of agitation, aggression, and previous behavioral issues, including verbal and physical outbursts. The facility's records indicated that the resident who perpetrated the abuse had a care plan in place addressing their aggressive behaviors, with interventions such as medication administration, behavioral redirection, and removal from public areas when disruptive. The victim also had a care plan noting risks for psychosocial well-being and a history of agitation and aggression. Despite these care plans, the incident occurred, resulting in the victim being found on the floor in pain, requiring emergency medical attention and subsequent hospitalization for surgical intervention. Documentation showed that staff responded to the incident by separating the residents, initiating neurological checks, and notifying the physician and resident representatives. The event was classified as physical abuse by the facility, and an internal investigation was initiated. The incident was reported to the appropriate protective authorities, and the facility's abuse prohibition policy was reviewed as part of the investigation.