Failure to Protect Resident from Physical Abuse by Roommate
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and agitation was not protected from physical abuse by her roommate, who had a history of aggressive behavior. The incident involved the roommate placing her hand over the resident's mouth and grabbing and squeezing her wrist while the resident was being cared for by a CNA. The resident complained of pain during the incident, and the roommate's actions were witnessed by staff. Prior to this event, the roommate had a documented pattern of aggressive and disruptive behavior toward both staff and other residents, including taking belongings, becoming combative, and making roommates uncomfortable. Staff interviews confirmed that the roommate had been moved multiple times due to issues with previous roommates, including an incident where she was caught putting a pillow over another resident's head. Despite these ongoing concerns, the roommate continued to be placed with new roommates, resulting in repeated disturbances and discomfort for others. The facility's policies require protection of residents from abuse by anyone, including other residents, and mandate measures to address factors that may lead to abusive situations. However, the facility failed to prevent the abusive incident, as evidenced by the roommate's continued aggressive behavior and the harm experienced by the resident. Interviews with staff and other residents further corroborated the roommate's pattern of aggression and the negative impact on those sharing a room with her.