Failure to Prevent Resident-on-Resident Physical Abuse Resulting in Head Injury
Penalty
Summary
The facility failed to protect residents from physical abuse when two alert male residents were involved in a physical altercation that resulted in injury. One resident with diagnoses including seizures, schizoaffective disorder, alcohol abuse, obesity, hypertension, major depressive disorder, and reflux reported going to another floor, speaking to another resident, and then being struck on the head with a cup, resulting in a head laceration that required stitches and left a visible healed mark on his forehead. Progress notes documented that this resident was observed with head lacerations and minimal bleeding and was transferred to the hospital, in part due to his known primary epileptic seizure disorder. The other resident, with diagnoses including lung disorders, end stage renal disease, heart failure, dependence on renal dialysis, HIV, anemia, and hyperkalemia, reported that the first resident repeatedly directed threatening and derogatory comments toward him when he went to get coffee and that, when the first resident approached and wanted to fight, he struck him with a coffee mug in what he described as self-defense. An LPN stated that this resident told her he could not get the other resident off him and that he hit him with a cup or something, while the injured resident reported that the other resident had been saying things that were triggering him. Another LPN on duty did not witness the incident and only became aware of it when a CNA reported that the residents were fighting; she then found the injured resident bleeding from the top of his head and learned from a roommate that the altercation started at the doorway and continued into the hallway. The administrator stated that the injured resident initiated the incident by being aggressive and getting in the other resident’s face before being struck, and facility policy defined physical abuse as the willful infliction of injury resulting in physical harm, pain, or mental anguish, including hitting and similar acts.
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