Failure to Prevent Resident-to-Resident Abuse Resulting in Physical Harm
Penalty
Summary
A resident with a history of Wernicke's encephalopathy, alcohol dependence, and atrial fibrillation, and who had demonstrated moderately impaired cognition, was involved in multiple incidents of aggressive behavior toward roommates. The resident's care plan identified previous altercations, including grabbing a roommate's shirt and making verbal threats. Despite these documented behaviors and recommendations for staff intervention and psychiatric support, the resident was returned to a shared room after a period in a private room, following the discharge of a previous roommate. A new roommate, who had severe cognitive impairment and was dependent on staff for mobility and transfers, was admitted to the same room. Shortly after, staff witnessed the first resident dragging the new roommate by the arm and throwing them into the hallway. The new roommate sustained superficial abrasions and a skin tear, and was transferred to the hospital for evaluation. Interviews with staff confirmed that the aggressive resident had a known history of altercations related to noise and that staff were aware of the risks associated with placing another resident in the same room. The facility's abuse policy prohibits mistreatment of any kind, including resident-to-resident abuse. Despite this, the decision to place a vulnerable resident in a shared room with a resident known for aggressive behavior resulted in physical harm. Staff interviews and documentation indicated that the aggressive resident should not have had a roommate due to prior incidents and impaired judgment, yet this precaution was not maintained.