Failure to Protect Resident from Physical Abuse by Roommate
Penalty
Summary
A resident reported being physically struck in the face by a roommate during a disagreement over television volume. The incident occurred while both residents were in their shared room, with the aggressor standing close to the other resident and making contact with his fist to the left cheek and part of the nose. The resident who was struck also reported being threatened by the roommate as he was escorted out of the room. The incident was witnessed by staff who responded to the altercation after hearing noise and attempted to separate the residents. Initial assessments found no visible injuries on the resident who was struck. The involved residents both had cognitive assessments indicating they were cognitively intact. The resident who was struck had a history of chronic medical and psychiatric conditions, including heart failure, bipolar disorder, and major depressive disorder with psychotic symptoms. The aggressor had a history of hemiplegia, alcohol abuse, and liver disease. Staff interviews and documentation indicated that the altercation was preceded by an argument about television volume, and that staff intervened after the incident had already occurred. There was no indication that staff were aware of escalating tension prior to the physical contact. Facility records and staff statements confirmed that the residents were separated following the incident, and the aggressor was sent for psychiatric evaluation. The facility's abuse and neglect policy defines abuse as the willful infliction of mistreatment or injury, including actions that result in harm even if not intended. The deficiency was identified due to the facility's failure to ensure that residents were protected from abuse by another resident, as required by policy and regulation.