Failure to Protect Resident from Physical Abuse by Roommate
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and significant physical limitations was subjected to physical abuse by his roommate. The incident involved the roommate striking the resident multiple times in the face with a fist, resulting in multiple injuries including hematomas and lacerations to the face, nose, lip, chin, and hand. The injuries were severe enough to require transfer to an acute care hospital for evaluation and suturing. The resident was observed with a bloody face and was later readmitted to the facility with visible wounds closed by stitches and ongoing hematomas and bruising. The abused resident had a history of cerebral infarction with hemiplegia and hemiparesis, as well as dementia, and was dependent on staff for most activities of daily living. At the time of the incident, the resident was calling for nursing assistance, which reportedly triggered the roommate's aggressive behavior. The roommate, who also had severely impaired cognition and a history of alcohol dependence, became agitated and physically assaulted the resident. Staff became aware of the incident after hearing screaming and entered the room to find the injured resident and the roommate unable to explain the event. The facility's policy on abuse prevention and resident safety was not effectively implemented, as evidenced by the occurrence of the assault and the resulting harm to the resident. The Director of Nursing confirmed that the incident constituted physical abuse and resulted in actual harm. The report documents the sequence of events, the residents' medical and cognitive conditions, and the immediate observations and assessments following the incident.