Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Shoulder Fracture and Psychosocial Harm
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident from resident-to-resident physical abuse. Late in the evening, one resident was suddenly attacked by another male resident who approached from behind while the victim was standing at the ice machine holding a cup. The aggressor placed both arms around the resident’s upper torso and neck area, putting him in a headlock. Staff and another resident intervened to separate them. Multiple staff, including an RN and a CNA, as well as the resident’s roommate, described the event as an unprovoked physical attack or physical abuse. The Administrator, who serves as the Abuse Coordinator, reviewed security camera footage and confirmed that the aggressor made physical contact and had his arms around the resident from behind. Following the incident, the resident reported new, severe left shoulder pain that began after the attack, distinct from his pre-existing chronic cervical and back pain from a decades-old accident. He consistently rated his shoulder pain as 8–10/10, described it as severe and unbearable, and reported that it was not relieved by his current pain medications. Nursing documentation reflected ongoing high pain scores and limited range of motion in the left shoulder. An X-ray later showed an acute or subacute inferior glenoid fracture fragment of the left shoulder, and the resident continued to experience significant pain with shoulder movement. The resident stated he had repeatedly requested an X-ray and to be sent to the hospital to assess the injury. The resident also experienced psychosocial distress after the assault. He reported feeling on edge, anxious, fearful of encountering the aggressor again, and hesitant to use common areas where the abuse occurred. He described intrusive recollection of the aggressor’s statement, “I’m here for murder,” which he heard during the altercation and which replayed in his mind, causing fear and distress. He reported difficulty sleeping, frequent nighttime awakenings, feeling more depressed and withdrawn, and no longer feeling safe in the facility. A psychiatric NP noted that the resident’s reported symptoms of heightened anxiety, hypervigilance, disrupted sleep, and worsening mood were not consistent with his baseline and were characteristic of an acute traumatic response. Both the in-house NP and psychiatric NP emphasized that pain and psychological distress are subjective experiences that must be taken seriously regardless of mental or psychiatric status. The facility’s own abuse policy affirms residents’ rights to be free from abuse and defines abuse as the willful infliction of injury or intimidation resulting in physical harm, pain, or mental anguish.
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