Failure to Prevent Resident-on-Resident Abuse
Penalty
Summary
The facility failed to prevent abuse between residents, specifically involving a resident with severe cognitive impairment who repeatedly threatened and ultimately physically assaulted their roommate, who also had severe cognitive impairment and decreased physical mobility. The first incident involved verbal threats and aggressive language directed at the roommate, with staff intervention and short-term monitoring, but no room change or psychiatric consultation was initiated at that time. Staff and CNA interviews revealed that threatening behavior and verbal aggression from the resident continued over a period of weeks, with multiple reports made to nursing staff. Despite ongoing threats and escalating behaviors, the residents continued to share a room. Staff were aware of the repeated threats and verbal altercations, but interventions such as room changes or psychiatric evaluations were not consistently implemented. The facility's Director of Nursing and Administrator cited a lack of available beds and did not recall or act upon all reported incidents. Documentation of one-on-one monitoring after the second incident was not provided, and there was no evidence of consistent or effective measures to separate the residents or address the aggressive behaviors. The situation culminated in a physical assault, where the aggressive resident struck their roommate on the forehead with a remote control, resulting in visible injury and bleeding. Staff responded to the incident, provided treatment, and initiated neuro checks, but the failure to act on prior threats and to implement protective interventions contributed to the occurrence of abuse. The facility's policy required protection from abuse and management of aggressive behaviors, but these measures were not adequately followed, leading to the cited deficiency.