F0600

D

Failure to Protect Resident From Physical Abuse by Roommate With Known Aggressive Behaviors

Lakewood, Colorado Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect one resident from physical abuse by another resident during an unwitnessed altercation in a shared room. The facility’s abuse prevention policy states that residents have the right to be free from abuse, including physical abuse, and that they must be protected from harm. On the date of the incident, a resident with schizoaffective disorder left his room and reported to a CNA that he had hit his roommate in the head multiple times because voices told him to do so. The altercation was not witnessed by staff, and the facility’s own investigation confirmed that the assault occurred based on the statements of both residents.

The resident who committed the assault was younger than 65 and had documented diagnoses including unspecified schizoaffective disorder, unspecified affective mood disorder, and hallucinations, with a history of behavioral symptoms such as physical and verbal aggression. His MDS showed he was cognitively intact and independent in mobility, and his care plans documented targeted behaviors including internal stimuli, auditory hallucinations, delusions, and aggression. The behavior and schizoaffective disorder care plans also documented that he had been recently involved in two separate resident-to-resident altercations, and staff interviews confirmed he had a history of such altercations, including punching a prior roommate. Despite this known history and identified risk for aggressive behavior toward peers, he remained in a shared room where he was able to physically assault his roommate while the roommate was in bed.

The victim of the assault was over 65 with diagnoses including intracranial injury, dementia, post-traumatic stress disorder, and major depressive disorder, and had moderate cognitive impairment per his MDS. He required varying levels of assistance with ADLs and had a trauma-informed care plan identifying him as at risk for decreased psychosocial well-being and emotional distress. On the day of the incident, nursing documentation recorded that the assailant admitted to hitting this resident two to three times in the head while he was sleeping. When assessed, the victim denied pain, loss of consciousness, and fear, and stated his roommate had “just went crazy.” Staff interviews indicated that the assailant was known to be easily agitated and had a history of resident-to-resident altercations, and that a room change for him had been delayed. The combination of the assailant’s known aggressive behaviors, his documented history of altercations, and the continued placement in a shared room led to the failure to keep the victim free from physical abuse.

Staff interviews further showed gaps in awareness and implementation of behavior management interventions. A CNA reported that the assailant had been involved in a prior altercation two to three weeks earlier, also self-reported by the resident, and that the victim was only moved to a different room after the current altercation. An RN stated that the resident’s triggers included hearing voices and that care plan updates were important for safety, but she was unsure why there was a delay in changing the assailant’s room. The social services director acknowledged the resident’s history of altercations and stated that previous root causes were related to auditory hallucinations, and that a room change was delayed due to another resident occupying the room and the need for a five-day room change notification. The NHA was unable to state what specific interventions were in place to manage the resident’s anger-related outbursts after the altercation. These circumstances, combined with the known behavioral history and risk factors, resulted in the facility’s failure to ensure that the victim was protected from physical abuse by his roommate.

The facility’s investigation concluded that the altercation was substantiated, with both residents confirming the incident. Documentation indicated that the incident did not cause injury or psychosocial stress according to the facility’s assessment, but the core deficiency remained that a resident with known aggressive behaviors and hallucinations was able to physically assault his roommate in their shared room. The facility’s own records and staff interviews demonstrate that the assailant’s behavioral risks and prior altercations were known, yet he remained in a situation where he could and did inflict physical abuse on another resident, contrary to the facility’s abuse prevention policy and the residents’ right to be free from abuse.