Resident Assaulted and Threatened with Knife by Roommate
Penalty
Summary
A deficiency occurred when a resident with a history of aggressive behaviors physically assaulted their roommate by punching them in the face and threatening them with a sharp knife. The incident took place in a shared room, where both residents had cognitive or psychiatric diagnoses, including schizoaffective disorder, bipolar disorder, and substance abuse. The aggressor had previously demonstrated verbal and physical aggression, and their care plan noted a potential for such behaviors. At the time of the incident, both residents were on one-to-one observation, but the assigned staff were sitting in the hallway with the door closed, rather than inside the room. This allowed the aggressive resident to move their bed next to the roommate's, initiate a verbal altercation, and escalate to physical violence and a threat with a weapon. Staff only intervened after hearing the commotion, at which point they entered the room, witnessed the altercation, and called for additional help. The assaulted resident sustained moderate swelling to the right eye and refused an x-ray. Both residents were assessed following the incident, and the aggressor was found to be in possession of a pocket knife, which was later recovered from the room. The facility's abuse prevention policy required screening for potentially abusive residents and protection of residents during investigations, but the events indicate that these measures were not sufficient to prevent the altercation and threat.