Failure to Protect Resident from Emotional Distress Due to Unaddressed Roommate Concerns
Penalty
Summary
The facility failed to protect a female resident's right to be free from abuse and neglect when she expressed discomfort and a lack of safety sharing a room with a male resident. Despite the resident's repeated statements that she did not know her roommate, did not want to be in the same room with him, and described him as 'creepy' and 'weird,' the facility did not address her concerns or take action to separate them. The resident, who had a history of dementia, anxiety, depression, bipolar disorder, schizophrenia, and a BIMS score indicating moderate to severe cognitive impairment, exhibited increased confusion, exit-seeking behaviors, and distress related to her roommate. Progress notes documented her confusion, refusal to return to her room, and requests for help to leave the situation, yet staff continued to redirect her back to the same environment without reassessing her safety or consent to the living arrangement. The care plans for both residents did not address their cohabitation or relationship, and there was no assessment of the female resident's capacity to consent to the relationship after her cognitive decline. Staff interviews revealed that although the residents had previously been considered companions, the female resident's cognitive status had changed significantly, leading her to no longer recognize her roommate or recall their relationship. Multiple staff members noted her discomfort and confusion, but the facility did not implement interventions to ensure her safety or dignity, nor did they update her care plan to reflect her wishes or current condition. Facility policy required immediate protection of residents suspected of being abused or neglected, including assessment and intervention to prevent further harm. However, the facility did not follow these procedures when the resident's statements and behaviors indicated distress and a lack of consent to her living situation. The deficiency was identified through observation, interviews, and record review, and it was determined that the facility's failure to act placed the resident at risk for emotional harm and mental anguish.