Failure to Prevent Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when one resident physically assaulted another in the hallway. On the morning of the incident, one resident, who had a documented history of verbal and physical aggression, stood up from his wheelchair, grabbed another resident, pinned them against a door, struck their head against the door, and punched them in the face. This resulted in the victim sustaining redness and pain to the left eye, with a pain rating of three out of ten. The incident was witnessed by both a CNA and an LVN, who confirmed the aggressive actions and the use of racial slurs during the altercation. The resident who committed the abuse had a care plan in place for aggression, which included monitoring behavior every shift. However, records revealed multiple prior incidents of aggressive behavior, including several change in condition (COC) events related to aggression in the months leading up to the incident. Despite these documented behaviors, there was no evidence of a psychiatric evaluation or consistent 72-hour monitoring following previous aggressive episodes. Additionally, progress notes did not indicate social services visits after aggressive incidents, suggesting a lack of follow-up and intervention. The victim of the abuse had severe cognitive impairment and a history of encephalopathy, major depressive disorder, and generalized anxiety disorder. The facility's own policies required protection of residents from abuse by anyone, including other residents. Interviews with staff and review of facility policies confirmed that the actions constituted both physical and verbal abuse, and that the facility failed to ensure the safety and well-being of the residents involved.