Failure to Protect Resident from Physical Abuse by Roommate
Penalty
Summary
A deficiency occurred when a resident was not protected from physical abuse by another resident. On the day of the incident, two residents sharing a room were involved in a physical altercation. One resident, who had a history of behavioral and emotional challenges, became upset after his roommate had a bowel movement on his own bed and threatened to do the same on the other resident's bed. The upset resident then pushed his roommate in the back with three fingers, causing the roommate to fall to the floor in a semi-sitting position, leaning on his right side. The resident who was pushed had multiple diagnoses, including schizoaffective disorder, major depressive disorder, and osteoarthritis, and required moderate assistance with several activities of daily living. The resident's cognitive functioning was moderately impaired. The resident who did the pushing had intact cognitive functioning but a documented history of verbal disagreements with his roommate. Multiple staff members, including an LVN and an RN, confirmed that the incident was an act of physical abuse and recognized the potential for injury. The incident was witnessed and reported by another resident and staff, and both residents involved admitted to their actions during interviews. The facility's abuse prevention policy, which maintains zero tolerance for abuse, was not upheld in this instance, as the resident was subjected to physical abuse by another resident while under the care of the facility.