Failure to Prevent Resident-to-Resident Abuse Following Inappropriate Room Assignment
Penalty
Summary
A resident with severe physical disabilities, including bilateral lower limb amputations and upper extremity contractures, was subjected to physical abuse by another resident. The abused resident was totally dependent for all care and had a history of vascular dementia, bipolar disorder, depression, and schizophrenia. The incident resulted in the resident sustaining a black eye and facial contusions. The resident was unable to defend himself due to his physical limitations and required assistance for all activities of daily living. The facility failed to prevent the abusive incident, which occurred after a room transfer placed the aggressive resident as a roommate with the vulnerable resident. The aggressive resident had a history of verbal aggression and was known to be manipulative, with staff and social services noting concerns about his behavior. The decision to pair these two residents was made by the interdisciplinary team, but staff later acknowledged that it was not a good fit. There was no evidence that the family of the vulnerable resident was notified of the new roommate, and the facility lacked a formal bed transfer policy. Staff interviews revealed that the incident was not witnessed, and the injury was only discovered during routine care. The facility also lacked a supervision policy for monitoring resident safety, and there was no documentation of a behavioral assessment or increased supervision for the aggressive resident prior to the incident. The event was reported to the police, and both residents exhibited physical signs consistent with an altercation. The facility's failure to properly assess roommate compatibility, notify families, and implement appropriate supervision contributed to the occurrence of resident-to-resident abuse.