Failure to Protect Resident From Peer Physical Abuse and Inadequate Incident Assessment
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident and to properly assess and document the incident. One resident (R1), with diagnoses including schizophrenia and bipolar-type schizoaffective disorder and a documented history of criminal behavior (aggravated battery with great bodily harm and attempted murder), physically struck another resident (R2) in the dining room. R2, who has major depressive disorder, post-traumatic stress disorder, nonsuicidal self-harm, and a moderate risk score for abuse/neglect, reported being hit multiple times in the head and face by a heavy-set Black man after an exchange of words. R1 confirmed hitting R2 in the head with a closed fist because R1 believed R2 was making fun of R1’s laugh, and a behavior aide reported seeing R1 give R2 “a couple taps” with a closed fist, which the aide stated would be considered physical abuse. Following the altercation, facility staff did not adequately investigate or document the event from R2’s perspective. The PRSC stated being told there was verbal back-and-forth between residents but denied being informed that any resident had gotten physical and denied speaking with R2 about the incident. An LPN reported being told that R1 was aggressive toward R2 and that R1 tried to hit R2, but did not ask staff whether the residents made contact and did not ask R1 if R1 hit R2, relying only on what others reported. There was no documentation of the altercation in R2’s notes, despite R2’s later account that there was definite physical contact and multiple hits before staff intervened, and that the touching was unwanted. The facility’s documentation and statements also show inconsistencies regarding R2’s involvement and the nature of the incident. Social service notes for R2 on the days following the event only record wellness checks, stable mood, and R2 reporting feeling safe, with no mention of the physical altercation. The administrator provided an alleged written statement from R2 about the incident, but the document was undated, and R2 denied ever seeing or signing it. When shown the document, R2 stated the signature was not his and demonstrated his usual signature, which did not match the one on the paper. The facility’s abuse prevention policy defines abuse as willful infliction of injury and specifies that physical abuse includes hitting and other non-accidental infliction of injury, yet the facility failed to ensure that R2 was free from physical abuse by R1 and failed to accurately assess, interview, and document R2’s experience of the incident.
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