Failure to Prevent Resident-to-Resident Physical and Verbal Abuse in Activity Room
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident with a documented history of multiple past traumas from physical and verbal abuse by another resident. The alleged victim had anoxic brain damage, mood disorder, depression, PTSD, and speech disturbance, and had been care planned as positive for adult sexual abuse, child physical abuse, domestic violence, and vehicular victimization, with interventions to avoid re‑traumatization. A quarterly MDS showed moderately impaired cognition with a BIMS score of 9. On the date of the incident, a nursing note documented that the resident was found on the floor crying, non‑verbal but able to indicate that another resident had pushed her, and that she had pain in her head and knee after hitting her head. The alleged perpetrator had anoxic brain damage, bipolar disorder, anxiety, seizures, and a cognitive communication deficit, with a care plan noting a history of substance abuse and mental health disorder and interventions to monitor for depression. A quarterly MDS showed intact cognition with a BIMS score of 15. Staff and resident interviews consistently described an altercation in the activity room involving three residents who had been doing karaoke. Witness accounts indicated that the alleged perpetrator became upset when the alleged victim was using her phone, believed she was communicating with someone else, and attempted to take the phone. When the alleged victim refused, the alleged perpetrator began yelling profanities, grabbed her around the neck area, and pulled or dragged her from her wheelchair, causing her head to strike a table before both residents fell to the floor. The alleged victim was observed on the floor crying and later reported feeling scared and hurt on the left side of her head. A witness resident reported that the alleged perpetrator yelled threats, including “I will kill you,” and called the alleged victim derogatory names, while the victim asked not to be left alone. Staff interviews, including an LPN, a life enrichment associate, and the DON, characterized the event as resident‑to‑resident physical abuse, with some also identifying verbal and emotional abuse. Facility policies on resident rights and abuse defined residents’ right to be free from abuse and described physical abuse as including hitting and controlling behavior through corporal punishment. Despite these policies and the known trauma history and vulnerabilities of the alleged victim, the incident occurred in a supervised activity setting, resulting in the resident being physically assaulted and verbally threatened by another resident.
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