Failure to Prevent Resident-on-Resident Abuse by Known Aggressive Resident
Penalty
Summary
The facility failed to protect a resident from abuse when one resident threw hot coffee on another resident. The resident who committed the act had intact cognition, a diagnosis of schizoaffective disorder, and a documented history of physical and verbal aggression, including throwing liquid at a peer and calling a roommate an “idiot.” His background check and an identified offender care plan showed felony convictions for aggravated battery and battery with bodily harm, and he was to be monitored and supervised. Despite this known history and care plan directives, he was able to obtain coffee during lunch service and throw it on another cognitively intact resident during an interaction in which he reported being annoyed by her talking. The resident who was the target of the coffee-throwing incident had diagnoses including malignant neoplasm of the colon, liver, and intrahepatic bile duct, schizophrenia, epilepsy, and low back pain, with intact cognition. An activity aide witnessed the incident, reporting that the aggressive resident threw coffee at the other resident after they had been speaking and she got up. Progress notes documented that the aggressive resident admitted throwing coffee because he found the other resident annoying. The facility’s Final Incident Investigation Report inaccurately stated that the aggressive resident had no history of verbal aggression with peers and concluded the allegation of abuse was unfounded, despite documentation of prior verbal abuse and the resident’s own admission to throwing the beverage.
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