Failure to Prevent Resident-to-Resident Physical Abuse Following Missed Room Change
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. One resident, who had a history of stroke and lack of coordination and was cognitively intact, made a statement about intending to harm their roommate, who also had cognitive impairment and cancer but was cognitively intact. Following this threat, intensified monitoring with 15-minute checks was initiated, and a room change request was submitted to Social Services. However, there was no follow-up on the room change request, and the mandated relocation did not occur as scheduled. As a result of the facility's failure to adhere to its policy regarding urgent room changes in situations involving threats of resident-to-resident aggression, the resident who made the threat physically assaulted their roommate, causing facial injuries that required emergency room care. Both residents were subsequently sent to the hospital after the incident, and emergency services and police were called. The administrator acknowledged that immediate relocation and physician notification were required when a resident threatens to harm another resident, but these actions were not taken in a timely manner.