Failure to Protect Resident from Verbal Threats and Aggression by Roommate
Penalty
Summary
The facility failed to implement individualized and effective interventions to protect a resident with known yelling behavior from verbal threats and physical aggression by her roommate. On the evening of the incident, a certified nursing assistant (CNA) heard the resident screaming in a manner that was described as frightened and different from her usual vocalizations. Upon entering the room, the CNA observed the roommate standing over the resident, holding her down by the shoulder with a fist raised to her face, and verbally threatening to hit her if she did not stop yelling. The resident was visibly frightened, with a surprised look on her face, and became quiet after the intervention of the CNA. Multiple staff interviews and observations confirmed that the resident who was threatened is mostly non-verbal, calls out frequently as a means of communication, and does not understand how to use the call light. Staff reported that her calling out is her baseline behavior and that she is unable to express her needs verbally. The roommate who made the threats was on hospice care and had a history of room changes, some of which were related to roommate issues, but there was no clear documentation of previous aggressive incidents involving other residents. The roommate admitted to being agitated by the yelling and confirmed that she threatened and physically confronted the resident. A review of care plans and facility policies revealed that the interventions in place for the resident with yelling behavior were not sufficiently individualized or effective in preventing the incident. The care plan included general interventions such as explaining procedures and discussing behaviors, but did not address the specific risks associated with her communication style or the potential for conflict with roommates. Documentation and behavior monitoring for both residents were found to be lacking or incomplete, and staff did not consistently respond to the resident's calls for assistance. The facility's failure to implement and update appropriate interventions resulted in the resident experiencing fear and potential psychosocial distress.