Failure to Prevent Resident‑to‑Resident Physical Abuse Resulting in Facial Fractures
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident punched him in the face during an altercation on the smoking patio. The injured resident had intact cognition, capacity to make decisions, and was dependent on staff for ADLs and transfers, using a wheelchair and mechanical lift due to his size and functional status. According to the change of condition evaluation, the resident was involved in an altercation with another resident that resulted in him being hit in the face, causing a nosebleed and a raised area on the forehead. The resident reported that he threw coffee on the other resident after being cursed at and called fat. He was transferred to a GACH for evaluation, where ED documentation noted a nosebleed, a forehead hematoma, pain, headaches, and dizziness, and a CT scan showed an undetermined nasal bone fracture and a left orbital wall medial fracture. The other resident involved in the altercation had intact cognition, capacity to make decisions, and was largely independent with ADLs, using a wheelchair for mobility but able to walk independently. Documentation indicated that this resident and the injured resident were involved in a verbal and physical altercation in which the injured resident threw coffee on the other resident’s face, after which the other resident stood up and hit him in the face. In an interview, the second resident stated he hit the first resident in the nose because coffee had been thrown in his face and that the first resident had blocked the door with his wheelchair and threatened to throw coffee again if called names. The facility’s abuse prevention and prohibition policy stated that each resident had the right to be free from abuse, neglect, and mistreatment and that staff must not permit anyone to engage in verbal, mental, or physical abuse, but the altercation occurred and resulted in physical harm to the first resident.
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