Failure to Prevent Resident-to-Resident Physical Abuse on Patio
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from abuse when another resident physically assaulted him. One resident (Resident #2), who had encephalopathy, aphasia, hemiplegia/hemiparesis following a cerebral infarction, bipolar disorder, and anxiety disorder, had a documented history and care plan for potential physical behaviors, including alleged physical aggression toward other residents on three prior dates. His care plan included interventions such as psychiatric consultation, analysis of triggers, providing cues to alleviate anxiety, offering choices, and intervening as necessary to protect the rights and safety of others. Despite these identified risks and interventions, Resident #2 remained in common areas with other residents. On the day of the incident, Resident #2 and another resident (Resident #1) were seated on opposite sides of the outdoor patio. Resident #1, who had quadriplegia, epilepsy, bipolar disorder, and major depressive disorder, had no cognitive impairment per his MDS and was care planned for verbally abusive behaviors such as yelling and cursing at staff and his roommate. While seated outside, Resident #1 activated a task on his phone using a spoken phrase into his headset. According to Resident #1 and the Activity Director, Resident #2 appeared to believe Resident #1 was speaking to him. The Activity Director reported that after hearing Resident #1 activate his phone, Resident #2 suddenly stood up from his wheelchair, walked across the patio, and began swinging at Resident #1, delivering what she described as a “pretty exaggerated punch” to Resident #1’s face. Resident #1 stated that Resident #2 walked a distance across the patio and started swinging at him, causing excruciating pain, and that he felt helpless due to his limited arm and hand mobility. A progress note documented that Resident #2 “suddenly with his fist, hit the other resident on the face,” and Resident #1’s assessment noted facial pain to touch. Hospital documentation showed Resident #1 was evaluated for an alleged assault and discharged with instructions for a facial bruise. The facility’s abuse prevention policy stated residents have the right to be free from abuse and that the program includes identification of occurrences and patterns of potential mistreatment and implementation of changes to prevent future occurrences, but the incident occurred despite Resident #2’s known behavioral history and care-planned risks.
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