Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
A resident with multiple diagnoses, including HIV, hemiplegia, bipolar disorder, and moderate cognitive impairment, was involved in a physical altercation with his roommate, who had multiple sclerosis, major depressive disorder, and was cognitively intact. The altercation occurred after ongoing documented behavioral concerns and verbal aggression from the roommate, which were noted in psychiatric progress notes over several months. Despite these documented issues and the roommate's care plan indicating a potential for verbally abusive behaviors, the two residents continued to share a room. On the night of the incident, the cognitively intact resident struck his roommate in the eye following a verbal exchange, resulting in an abrasion and swelling. Interviews confirmed the history of verbal aggression and the physical altercation. The director of nursing acknowledged that roommates with documented behavioral concerns should be separated and that ongoing issues should have been communicated and addressed. Facility policy required identification and intervention in situations likely to result in abuse, but these measures were not implemented prior to the incident.