Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when a conflict between two residents escalated, resulting in one resident pushing an over-bed table that struck the other resident in the head. Prior to the incident, there were documented concerns: one resident had expressed unhappiness with his roommate several days earlier, and staff had observed ongoing verbal aggression between the two. Despite these warning signs, the facility did not take action to separate the residents or address the escalating conflict. Medical record reviews and staff interviews revealed that the resident who was ultimately injured had repeatedly requested a room change and informed both the charge nurse and CNAs about the ongoing issues. Staff, including CNAs and LVNs, were aware of the residents' verbal altercations and the request for a room change, but no action was taken to separate them. On the day of the incident, staff observed the residents engaging in verbal aggression, with one resident making a direct threat to harm the other. The residents were not separated at this point, and the situation escalated to physical violence. After the altercation, the injured resident was assessed and found to have a small movable mass with minimal redness and flaky skin on the head, and later reported ongoing headaches. Interviews with staff and the social services director confirmed that the concerns about the residents' compatibility and safety were not communicated or addressed in a timely manner. The facility's policy required immediate separation of residents in such situations, but this was not followed, resulting in harm to the resident.