Resident Not Protected from Physical Abuse by Roommate
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease and major depressive disorder, who had severely impaired cognitive skills and required significant assistance with daily activities, was left unsupervised in a room with another resident diagnosed with dementia, anxiety, and major depressive disorder. The first resident was in a wheelchair and had been informed by a CNA that it was time for a shower, to which the resident responded negatively. The second resident became upset by this response, displaying signs of agitation before the CNA left the room to retrieve a Hoyer lift, leaving both residents alone together. Within seconds of the CNA leaving, the second resident verbally cursed at the first resident, who questioned the behavior. The second resident then got out of bed, slapped the first resident on the right side of the face, and punched the resident in the stomach. The CNA returned quickly, intervened, and separated the residents. Staff interviews confirmed that the first resident was not protected from physical abuse, and that it was not acceptable to leave a vulnerable resident alone with an upset roommate, especially given the known risk of aggression. Facility staff, including the CNA, LVN, RN, and Administrator in Training, acknowledged that the incident was preventable and that the first resident was not adequately protected. The facility's abuse policy required immediate intervention and protection of residents from harm, but this was not followed, resulting in the first resident being subjected to physical abuse by another resident.