Failure to Prevent and Address Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse during two resident-to-resident incidents involving two cognitively intact residents with multiple medical diagnoses. One resident, who required maximal assistance with activities of daily living, was transferred into a shared room, which led to escalating tensions with their roommate. The roommate, who had a history of behavioral episodes and vision concerns, became increasingly agitated over disagreements about room lighting and personal space. Despite prior verbal threats and staff awareness of ongoing conflicts, no effective interventions were implemented to prevent further escalation. On the day of the incident, the agitated resident used a metal reacher to strike their roommate in the leg following a verbal altercation about the room lights. Staff responded immediately to the incident, separated the residents, and contacted law enforcement. The assaulted resident reported pain and minor bruising but was not found to have sustained injuries upon subsequent assessment. The aggressor admitted to the physical act and showed no remorse, expressing ongoing dissatisfaction with having a roommate. Prior to the physical altercation, staff and social work documentation indicated awareness of repeated verbal threats and behavioral issues, including the resident's calls to 911 and explicit statements about not wanting a roommate. Despite these warning signs, the facility did not update care plans or implement interventions to mitigate the risk of abuse. Additionally, there was a delay in reporting the verbal abuse to facility leadership, and the incident was not documented in the assaulted resident's medical record as expected. The facility's failure to act on known risks and to document and communicate incidents contributed to the deficiency.