Failure to Protect Resident from Physical Abuse by Roommate
Penalty
Summary
A resident with severe cognitive impairment and multiple diagnoses, including non-traumatic brain dysfunction and dementia, was subjected to physical abuse by their roommate. The resident required substantial to maximal assistance for mobility and had recently returned to the facility after being away for a few days. The incident occurred when another resident entered the room and was observed by staff hitting the resident in the head while the victim was seated in a wheelchair. The assaulted resident was found to have redness on the head and later complained of intermittent headaches following the incident. Staff interviews and medical record reviews confirmed that the two residents had a history of bickering, but there was no clear indication of what provoked the physical altercation. The staff member who witnessed the event reported hearing yelling and seeing the aggressor striking the resident, while the victim did not verbally respond during the incident. The nurse who assessed the situation noted mild redness to the back of the resident's head and documented that the resident expressed feeling unsafe with the aggressor as a roommate. The facility's policy states that residents will be protected from abuse, neglect, and harm while residing at the facility. Despite this, the resident was not protected from physical abuse by another resident, resulting in actual physical harm. The incident was witnessed by staff, and documentation indicated that the resident felt unsafe following the event.