Failure to Protect Resident From Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident struck him in the head with a chair. One resident, with Alzheimer's disease, Parkinson's disease, agitation, and severe cognitive impairment (BIMS score 4/15), was found by an RN sitting on the floor in the doorway of another resident's room with blood coming from the left side of his forehead. The injured resident could not recall going to the emergency department or how his head was injured. Progress notes documented a laceration on the left side of his forehead, and an acute care hospital encounter summary indicated a 4-centimeter laceration requiring stitches. The other resident involved had diagnoses of metabolic encephalopathy, anxiety, and adjustment disorder with mixed disturbance of emotions and conduct, and his MDS indicated he sometimes made himself understood and sometimes understood others. This resident's care plan, dated the same day as the incident, documented a history of physical and verbal aggression, including hitting, pushing, threatening, and throwing objects, with observed aggressive behavior toward staff and residents. During an interview, this resident stated he hit the other resident in the head with a chair because he was angry about being awakened. At the time of the incident, the RN observed this resident standing in his room holding a chair and screaming, while the injured resident was bleeding in the doorway. The facility had a policy stating residents have the right to be free from abuse, neglect, misappropriation of property, and exploitation.
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