Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from abuse and neglect, specifically failing to prevent one resident from physically assaulting another. One resident, who had a history of major depressive disorder and chronic diarrhea, was involved in a conflict with his roommate, who had diagnoses of bipolar disorder with psychotic features and generalized anxiety disorder. The conflict escalated due to ongoing arguments about hygiene and odor related to the first resident's medical condition. Despite both residents having intact cognition, their interpersonal issues were not identified or addressed by staff prior to the incident. On the day of the incident, the resident with chronic diarrhea exited the bathroom and discussed showering with a CNA, while his roommate overheard the conversation and became increasingly agitated. The agitated resident followed his roommate to the therapy room, where he began yelling and cursing. Therapy staff attempted to verbally de-escalate the situation by asking the agitated resident to calm down and go for a walk, but these interventions were ineffective and further escalated his anger. The resident then approached his roommate, who was seated, and struck him in the nose. Staff present in the therapy room did not physically intervene to prevent the assault, and the assaulted resident later expressed that if someone had stepped in front of him, he would not have been hit. Interviews with staff revealed that they were unaware of any prior arguments between the two residents and did not anticipate the escalation. The Director of Therapy acknowledged that the interventions used were not appropriate and that removing the assaulted resident from the situation would have been a better response. The facility's policy on abuse and neglect emphasizes the responsibility of staff to recognize and promptly intervene in situations that may constitute abuse, but in this case, staff failed to protect the resident from physical harm.