Failure to Assess Room Compatibility Leads to Resident-to-Resident Assault
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident due to inadequate assessment and documentation during multiple room changes. One resident, diagnosed with dementia and anxiety, had a known intolerance to noise but was moved between rooms several times without proper evaluation of his individual needs or compatibility with roommates. Staff did not document the reasons for these room changes or assess the potential for conflict, despite the resident's history of being upset by noise and previous incidents of agitation with other roommates. This lack of assessment and documentation led to the resident being placed in a room with another individual who exhibited frequent moaning, mumbling, and yelling due to severe cognitive impairment and was receiving hospice care. The noise triggered the first resident, resulting in a violent assault. The assaulted resident sustained severe injuries, including lacerations to the head, extensive facial fractures, rib fractures, and a vertebral fracture, and subsequently passed away in the hospital. The incident was unwitnessed, but the aggressor admitted to hitting the roommate due to the noise. Interviews with staff revealed that the process for room changes did not include consistent documentation of assessments or reasons for moves, and staff were aware of the aggressor's intolerance to noise. Facility policies required assessment of compatibility and documentation for room changes, but these procedures were not followed. The failure to assess and document resident needs and preferences during room changes directly contributed to the altercation and resulting harm.