Failure to Protect Resident from Verbal and Physical Abuse by Roommate
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple psychiatric diagnoses was not protected from verbal and physical abuse by a roommate, who also had severe cognitive impairment and a history of behavioral disturbances. The two residents were assigned to share a room after the first resident was moved due to inappropriate sexual behaviors by a previous roommate. Staff were aware of both residents' behavioral histories, including the second resident's aggressive tendencies and the first resident's vulnerability due to dementia and confusion. The incident leading to the deficiency involved the second resident becoming verbally and physically aggressive toward the first resident, including yelling inappropriate language and punching the resident while in bed. Staff intervened immediately upon hearing the altercation, separated the residents, and assessed the first resident for injuries. Documentation and interviews confirmed that the first resident did not exhibit aggressive behaviors and was calm and nonreactive during the event, while the second resident had previously expressed frustration about the roommate's behaviors and admitted to staff that he had taken matters into his own hands due to perceived lack of staff intervention. Despite knowledge of both residents' behavioral histories and the potential for conflict, the facility assigned them as roommates. Staff interviews revealed concerns about the compatibility of the room assignment, and there was a lack of awareness among some staff regarding the behavior care plans in place. The facility's failure to adequately assess and prevent the risk of resident-to-resident abuse resulted in the first resident being subjected to verbal and physical abuse, violating the resident's right to safety.