Failure to Prevent Verbal Abuse Between Roommates
Penalty
Summary
The facility failed to protect a resident from verbal abuse, as evidenced by an incident involving two residents sharing a room. One resident, who had a history of alcohol abuse, cognitive impairment, and multiple medical diagnoses, was moved into a room with another resident who had moderate cognitive impairment and required significant assistance with activities of daily living. Shortly after the room change, both residents engaged in a verbal altercation, during which one resident threatened the other with bodily harm. This exchange was witnessed by a housekeeper, who confirmed hearing the threat and the yelling from the nurse's station. The facility's Abuse Prevention Program policy requires staff to identify residents with increased vulnerability to abuse and to implement care planning strategies to reduce the risk of abuse, neglect, or mistreatment. Despite these requirements, the care planning and monitoring processes did not prevent the verbal abuse incident. The resident who was threatened reported that his belongings were moved without his knowledge and that he was subjected to yelling and threats of bodily injury by his roommate. Staff intervention occurred only after the altercation, when the threatened resident was moved to another room.