Failure to Prevent Resident-to-Resident Verbal and Physical Abuse
Penalty
Summary
The facility failed to protect a resident from verbal and physical abuse by another resident, contrary to its policy titled "Abuse, Neglect and Exploitation." On the date of the incident, one resident with Alzheimer's disease with late onset, psychotic disturbance, mood disturbance, and anxiety (R38) was ambulating in the hallway when another resident (R44) began yelling profanities at staff and then became aggressive toward R38. According to the facility incident report and progress notes, R44 verbally and physically assaulted R38, striking him repeatedly in the head, which caused R38 to fall and hit his head on the ground. Nursing assessment documented bruising to R38's left cheek, and R38 was unable to recall what had happened. Record review showed that R44 had been admitted with schizoaffective disorder, bipolar type, and an unspecified focal traumatic brain injury with loss of consciousness of unspecified duration, and had a documented history of behaviors related to schizophrenia, including a prior altercation with another resident and verbal and physical aggression toward staff. On the day of the incident, R44 was attempting to get into a bathroom near the nurse station and was being redirected by nursing staff when R38 was walking up the hall, at which point R44 escalated from yelling profanities at staff to physically attacking R38. The incident demonstrates that the facility did not prevent resident-to-resident abuse, resulting in one resident being verbally and physically assaulted by another resident with a known history of aggressive behaviors.
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