Failure to Prevent Repeated Resident-on-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect two residents from physical abuse by another resident with a known history of physical aggression related to mental illness. One resident had severely impaired cognition, bipolar disorder with psychotic features, a history of traumatic brain injury, and exhibited verbal behaviors directed at others. Another resident had intact cognition but carried diagnoses including schizophrenia, borderline personality disorder, obsessive compulsive disorder, and bipolar disorder. The aggressive resident had a care plan in place since admission identifying potential for physical aggression and interventions such as counseling on conflict management, walking away from peers, and seeking staff assistance when conflicts arose. On one occasion, staff witnessed the aggressive resident strike a cognitively impaired resident in the dining room. The injured resident reported being hit in the face by the aggressor. A general note documented a skin tear to the left chin, and the resident was sent to the hospital, where a thick layer of dermal glue was applied and bruising to the left eye was noted. Although the self-reported incident and investigation confirmed that the aggressor hit the resident, the written witness statements and investigation did not document what object was used. In a later interview, the DON stated that the resident had been hit with a [NAME] that had a wooden handle and rubber head, and staff believed the object was obtained from a maintenance cart. On a separate occasion, the same aggressive resident struck another resident in the back of the head in a hallway following an argument over a composition notebook, which was later found in the aggressor’s room. A housekeeper reported seeing the argument that resulted in the aggressor hitting the other resident, and a CNA described the aggressor as very aggressive that morning. The injured resident sustained a laceration to the back of the head, was sent to the hospital, and returned with two staples in the crown of the head and a CT scan showing no additional anomalies. In an interview, this resident confirmed being hit in the head with a rock by the same aggressor and expressed relief that the aggressor was no longer present. These events demonstrate that the facility did not prevent physical abuse between residents despite prior knowledge of the aggressor’s behavioral risks and existing care plan interventions.
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