Failure to Prevent and Properly Investigate Resident-to-Resident Physical Assault
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse prevention policy to protect residents from resident-to-resident physical abuse. A resident with a history of psychosis, schizophrenia, bipolar disorder, auditory hallucinations, and prior hospitalization for aggressive behavior entered another resident’s room, became upset about what he believed was expired or spoiled milk, and began yelling. According to the assaulted resident and multiple resident witnesses, the aggressor struck the resident on the right side of the head with a milk carton, pushed her onto the bed, grabbed her upper arms, and shook her violently, continuing to hit her until another resident intervened and staff arrived. The assaulted resident reported pain in her right forearm and behind her right ear. Witness statements from two other residents consistently described the aggressor on top of and hitting the victim, and one resident physically pulled the aggressor away and stood between them. The aggressor’s medical record showed multiple psychotropic medications ordered for psychosis, schizophrenia, and bipolar disorder, but the MAR documented frequent refusals of these medications over an extended period, both before and after a recent hospitalization for aggressive behavior. There was no documentation that the attending physician or psychiatrist was notified each time these psychotropic medications were refused, and nurse practitioner notes during this period recorded “no concerns from the nursing staff.” The facility’s abuse investigation relied on written statements from residents but did not include any staff interviews regarding the event and concluded there was no credible evidence that abuse occurred, despite multiple resident accounts that the aggressor was hitting the victim. This sequence of events and omissions reflects a failure to follow the facility’s abuse prevention policy and to adequately address and monitor a resident with known psychiatric diagnoses and aggressive behavior, resulting in a resident-to-resident physical assault.
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