Failure to Protect Resident from Physical and Verbal Abuse
Penalty
Summary
Facility staff failed to protect a resident from abuse when another resident threw a dessert cup, striking the resident in the right eye during a hostile argument. Multiple staff and residents confirmed that the aggressor had a history of making verbal threats and had previously threatened to physically harm the victim. The incident occurred in a hallway while staff were attempting to separate the two residents during a verbal altercation. The resident who was struck reported feeling unsafe in the facility as a result of these ongoing threats and the physical altercation. Both residents involved had intact cognitive function as indicated by their BIMS scores. The resident who was struck had a history of major depressive disorder and bilateral below-the-knee amputation, while the aggressor had diagnoses including depression, anxiety disorder, and psychoactive substance abuse. Care plans for both residents noted potential for aggressive behavior, but the Director of Nursing and Administrator were unaware of the ongoing tension between the two residents. The facility's abuse prevention policy required staff to report any risks of abuse, but the ongoing threats and altercation were not effectively addressed prior to the incident.